Management Analysis and Service Office Request for Correction to Disseminated Information

Information Quality Home Guidelines for Ensuring the Quality of Information Disseminated to the Public Statute on Information Quality HHS Guidelines Public Inquiries (404) 639-3534 (800) 311-3435 Centers for Disease Control and Prevention 1600 Clifton Rd. Atlanta, GA 30333 U.S.A (404) 639-3311 * All references to CDC will apply to ATSDR unless otherwise indicated.

Requestor Information Last Name: First Name: Organizational Affiliation: Best Way for us to Contact you: E-Mail Phone USPS Mail E-Mail Address: Re-Enter E-Mail Address: Daytime Phone Number: (eg. 404-123-4567) Address: Type of Disseminated Information: Scientific Publication Speech/Interview/Presentation Website Media Other After selecting which type of Disseminated information you are submitting a request for, you must also fill the section corresponding to the type of your choice.   Scientific Publication Information Fill this section only if you choosed Scientific Publication type of Disseminated Information Scientific Publication Date: (eg. 11-11-2002) Scientific Publication Title: Scientific Publication Number:   Speech/Interview/Presentation Information Fill this section only if you choosed Speech/Interview/Presentation type of Disseminated Information Speech/Interview Date: (eg. 11-11-2002) Speech/Interview Title: Speech/Interview Presenter: Speech/Interview Place of Delivery:   Web Site Information Fill this section only if you choosed Web Site type of Disseminated Information Website Address (URL):   Media Fill this section only if you choosed Media type of Disseminated Information Media Type: Newspaper Radio TV Media Date:   Other Information Fill this section only if you choosed Other type of Disseminated Information Other Information:   Request for Correction Information Description of Information: Specific Reason(s) why Information Does Not Comply with OMB, HHS or CDC Guidelines (The proof of burden is the responsibility of the requestor): Requestor's Recommendation for Correction: How Were You (the requestor) Affected by the Information?

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