Contact Information

APPENDIX NUMBER 11: Contact Information

Form Approved

OMB NO. ________

Exp. Date ________

Public reporting burden of this collection of information is estimated to average 5 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, Georgia 30333; ATTN: PRA (0920-XXX)

THIS INFORMATION WILL BE KEPT PRIVATE.

IT WILL BE KEPT IN A LOCKED FILE AND WILL BE DESTROYED

IN THREE MONTHS.

Only SOL/Share project staff will have access to your contact information.

We will use this information to contact you, if necessary, while you are taking part in this study.

Interview Date: ___/___/___ (mm/dd/yy)

Participant Study Number
Last Name
First Name
Middle Initial
Do you go by any other names? (list aliases)	___________________________________ ___________________________________ ___________________________________ ___________________________________
What is your address? Is it OK to send a reminder card to you at this address?	Street:______________________________ Apt. #:______________________________ City: ______________________________ Zip Code:___________________________ Yes, it is OK No, it is not OK
What is your home phone number Is it OK to call you at this number? Is it OK to leave a message for you at this number? What is the best time to call you?	__________________________________ Yes, it is OK No, it is not OK Yes, it is OK No, it is not OK Days of week_______________________ Time of day________________________
What is your cell phone number? Is it OK to call you at this number? Is it OK to leave a message for you at this number? What is the best time to call you? Do you have an email address? What is it? Is it OK to send you an email message?	_________________________________ Yes, it is OK No, it is not OK Yes, it is OK No, it is not OK Days of week_______________________ Time of day________________________ __________________________________ Yes, it is OK No, it is not OK
Is there someone who always knows how to reach you? Who is that person? Is it OK to write to this person and ask how to reach you? Is it OK to call this person and ask how to reach you?	Name______________________________ Relationship: _______________________ Address____________________________ Apt. #:_____________________________ City:_______________________________ Zip Code:___________________________ Home Phone#:______________________ Cell Phone #:_______________________ Yes, it is OK No, it is not OK Yes, it is OK No, it is not OK
Is there another person who always knows how to reach you? Is it OK to write to this person and ask how to reach you? Is it OK to call this person and ask how to reach you?	Name______________________________ Relationship: _______________________ Address____________________________ Apt. #:_____________________________ City:_______________________________ Zip Code:___________________________ Home Phone#:______________________ Cell Phone #:_______________________ Yes, it is OK No, it is not OK Yes, it is OK No, it is not OK
1. Where do you like to hang out?? Is it OK to try to find you at this location? 2. Where else do you like to hang out?? Is it OK to try to find you at this location? 3. Where else do you like to hang out?? Is it OK to try to find you at this location?	Place______________________________ Location____________________________ ___________________________________ ___________________________________ Yes, it is OK No, it is not OK Place______________________________ Location____________________________ ___________________________________ ___________________________________ Yes, it is OK No, it is not OK Place______________________________ Location____________________________ ___________________________________ ___________________________________ Yes, it is OK No, it is not OK