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Your Environment. Your Health.

Screener Registration

Women's Health Awareness Day 2017

April 8, 2017 • 8:30 a.m. – 5:00 p.m.

OMB # 0925-0740

All required fields have the word (required) after the label.

If we need to contact you, what is the best time to contact you?
How did you hear about this event (required) Select all that apply.
Do you require special accommodations? (required)
Accommodations required Check all that apply
Please Note: Official NC Parking Decal required.
Are you a member of a Greek Sorority?
Delta Sigma Theta Sorority, Inc.
Alpha Kappa Alpha Sorority, Inc.
Zeta Phi Beta Sorority, Inc.
Sigma Gamma Rho Sorority, Inc.
Chi Eta Phi Sorority, Inc.
Iota Phi Lambda Sorority, Inc.

OMB # 0925-0740
Expiration Date: 05/31/2019

Public reporting burden for this collection of information is estimated to average 2 minutes per response, 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0740). Do not return the completed form to this address.

PLEASE NOTE: We will make every effort to ensure that your privacy and confidentiality are maintained. All records will be kept confidential to the extent provided by federal, state, and local law.

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