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):
________________________________________________________________
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 # _______________