0920-1150 Survey Screener

Confidential

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Upper Midwest Tickborne Disease Prevention Survey
Form Approved
OMB Control No.: 0920-1150
Expiration date: 12/31/2019

This research study is being conducted by your state health department, the Midwest Center of Excellence for
Vector-Borne Disease, and the Centers for Disease Control and Prevention. Your household has been randomly
selected to participate. We will ask you about any encounters you have had with ticks or diseases spread by ticks.
We will also ask about steps you take to avoid tick bites. Your responses will help us better understand how to
prevent tick bites and diseases spread by ticks.

Public reporting burden of this collection of information is estimated to average 10 minutes per response, including
the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not
required to respond to a collection of information unless it displays a currently valid OMB Control Number. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions
for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia
30333; ATTN: PRA 0920-1150.

Are you 18 years of age or older?
What is your age (in years)?

Yes

No

__________________________________

Are you the adult in your household with the most
recent birthday?

Yes
No

Currently, in which state do you live?

Michigan
Minnesota
Wisconsin
Other

05/24/2019 12:30pm

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