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  3. Service or Material Request Form

Service or Material Request Form

This request can be submitted to Casetta R. Simmons at CSimmons@cdc.gov by clicking on the Submit button at the bottom of the form.

* Indicates required information.

Requestor Information

 * Date Submitted   (mm/dd/yyyy)     * Date Needed     (mm/dd/yyyy)

 *Name     

   Title         

 *Address  

 *City                    * State                   *Zip 

  Phone                              Ext.                         FAX 

 *E-mail       



Service or Material Requested (check off what is needed)

     HSEES Public Use Dataset (to do your own data analysis)

Please mail me a CD
I will download from this website
     Custom Data Request (describe exactly what data is needed)
  

     HSEES Brochure (number of copies)
     HSEES Report Year(s) Number of Copies
     HSEES Protocol
     HSEES Data Collection Form and Training Manual
     Journal Article: Lead Author Year
           Title or Topic
     Clearance of HSEES related materials that will be disseminated
     Other (specify)
  



Will this information be disseminated in any way(i.e. as part of a fact sheet, report, presentation,
poster, journal article)
 Yes, redistributed as is (please complete rest of form)
Yes, as part of something new (please complete rest of form)
No (Thanks, you are finished)

PLEASE COMPLETE ALL OF THE INFORMATION SO THAT WE MAY CONTINUE TO JUSTIFY THIS PROGRAM AND PROVIDE THESE SERVICES

*Target Audience type(s) (i.e. EMS, Industry Saftey Personnel)

*Approximate Audience Number (i.e. copies distributed, attendees at the conference, or hits on website)

Intended purpose for requested materials (check off all appropriate)
  Internet site URL or name:
  Fact Sheet topic:
  Report topic: 
   Journal article topic:
    submitting to:
  Newsletter topic: 
    submitting to:
  . Poster or presentation for
a conference, meeting etc		 topic:

    Conference Name:

    Date (mm/dd/yyyy):
  General awareness
information on the program		    
       
  Other (specify)  

 


Is this an HSEES approved prevention outreach activity   yes   no

If not submitting online, submit to Casetta Simmons, ATSDR/DHS/SRB, 1600 Clifton Road, N.E.,
Mailstop E-31, Atlanta, GA 30333, Fax to 404-498-0077, E-mail CSimmons@cdc.gov

 

_______________________________For Official Use Only____________________________________

ID#___________Date Received__/__/____Date Completed__/__/____Initials____



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