Sample Questionnaire Survey

Board of Health Letterhead here.

July 25,1996

The Massachusetts Department of Public Health in conjunction with the XXXXX Board of Health is investigating an outbreak of gastrointestinal illness which occurred among the attendees of a business conference held at Establishment A on July 19,1996. Please complete these questions ONLY IF YOU ATTENDED the metting. Your completion of the following questions, EVEN IF YOU DID NOT HAVE ANY STMPTOMS, will greatly assist us in our efforts to identify the source of this illness. All information which you provide will be kept strictly confidential and used solely for the purposes of this investigation. Please return the completed questionaire to the XXXXX Board of Health at the address or fax below. Thank you for your assistance.

RETURN TO:

Board of Health (123) 456-7890 Fax: (123) 456-7781

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