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Division for Heart Disease and Stroke Prevention

4770 Buford Hwy, NE Mail Stop 107-1 Atlanta, GA 30341-3717

Fax: 770-488-8151

Centers for Disease Control and Prevention

1600 Clifton Road Atlanta, GA 30329-4027 USA

800-CDC-INFO (800-232-4636)

OMB Number: 0920-0612 Expiration Date: 03/31/2025

Public reporting burden of this collection of information is estimated to average 24 hours per program including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports, Clearance Office; 1600 Clifton Road NE, MS D-74, Atlanta, GA 30333. Attn: PRA (0920-0612). Do not send the completed form to this address.

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