Historical Document
This document is provided by the Agency for Toxic Substances and Disease Registry (ATSDR) ONLY as an historical reference for the public health community. It is no longer being maintained and the data it contains may no longer be current and/or accurate.
Fax to: Casetta Simmons at 404-498-0079 or email to crrl@cdc.gov with a cc to your technical advisor. click here for printer friendly version.
Date faxed to state personnel: _____________
Date state responded: __________________
Description of previous data clearance request (Casetta will provide):
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Date activity was completed: __________________
Name (HSEES coordinator): _____________________________
City: ____________________ State: _________________
Phone Number: ___________________________
Actual Audience Number (i.e., the number of copies distributed, the attendees at the conference session, or the number of visitors at a website): ____________________
Feed-back/Success Story (A brief description of how the activity went. Please write clearly):
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Future Plans:
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Thanks and have a wonderful day!
------------------------ For Official Use Only -----------------------------------
Date received: ______________
Data Clearance Request # ___________ Follow-up # _______________
Agency for Toxic Substances and Disease Registry, 4770 Buford Hwy NE, Atlanta, GA 30341
Tel: (404) 498-0110 / Public Inquiries: (888) 422-8737
