Participant Contact Form

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Appendix M - Participant Contact Form

Appendix M

Form Approved

OMB No.

Exp. Date

Participant Contact Form

DATE: ______________

NAME: _______________________________________________________

TEL:__________________ ALTERNATE TEL: ___________________

OK TO LEAVE REMINDER MESSAGE? Y:_______ N: ________

BEST TIME TO REACH: ________________________________________________

CONTACT ACTIVITY

Date Time Contact Type Outcome (scheduled date/time?)

______ ______ ____________ ________________________

______ ______ ____________ ________________________

______ ______ ____________ ______________________

______ ______ ____________ ________________________

______ ______ ____________ ________________________

NOTES:

Public reporting burden of this collection of information is estimated to average 3 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 CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, GA 30333; ATTN: PRA (0920-XXXX).

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