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Management Analysis and Services Office
Request for Correction to Disseminated Information
Requestor Information
First Name: Please enter your first name
 Last Name: Please enter your last name
Organizational Affiliation:
Best way for us to contact you:
E-Mail      Phone      USPS Mail
E-Mail Address: Please enter a valid email address
 Re-Enter E-Mail address: Please verify email address
Daytime Phone Number: (eg: 404-555-1212)
Mailing Address: Please enter your address
Type of Disseminated Information:
Scientific Publication Speech/Interview/Presentation   Website Media Other
Please note: after selecting the type of disseminated information in the area above, you must also complete the section corresponding to your choice.  Click on the Information Type above to move to the appropriate section
 
Scientific Publication Information
Fill this section only if you chose Scientific Publication for the Type of Disseminated Information
Publication Date:
 Publication Number:
Publication Title
Speech/Interview/Presentation Information
Fill this section only if you chose Speech/Interview/Presentation for the Type of Disseminated Information
Date of Speech / Interview / Presentation:
 Speech / Interview / Presentation Place of Delivery
(Where did this speech / interview / presentation take place?):
Speech / Interview / Presentation Title:
Speech / Interview / Presentation Presenter:
Website Information
Fill this section only if you chose Website for the Type of Disseminated Information
Website Address (URL):
Media Information
Fill this section only if you chose Media for the Type of Disseminated Information
Newspaper Radio Television Media Date:
Other Information
Fill this section only if you chose Other for the Type of Disseminated Information
Other Information:
Request for Correction Information
Description of Information:
Specific reason(s) why you feel Information does not conply with OMB, DHHS, or CDC Guidelines (The burden of proof is the responsibility of the requestor) :
How would you recommend that this information be corrected?:
How were you affected by the information:
 
 
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