Form 2 Locator Form

Nurse Delivered Sexual Risk Reduction Intervention for

HIV-Positive Women in the South

0920-XXXX

Attachment 4

Locator Form

Form Approved

OMB No. 0920-XXXX

Exp. Date __xx/xx/20xx

Attachment 4

Sister to Sister Positive HOPE

Locator Information Form

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, Georgia 30333; Attn: PRA (0920-XXXX)

Name: Participant I.D. Number: _____________

Recruitment Date:

Telephone numbers where subject can be reached:

Name: Number: ( )

Name: Number: ( )

Name: Number: ( )

Home Address:

County:

Street Address:

City:

Zip Code:

Telephone numbers of other persons (relatives, partners, friends) where subject can be reached:

Name: Number: ( )

Name: Number: ( )

Name: Number: ( )

Home address:

County:

Street Address:

City:

Zip Code:

Mailing address if different:

Frequent Hang Outs:

1.

2.

3.

Services Used:

1.

2.

3.

Health Care Providers Used:

1.

2.

3.

Treatment Agencies Used: (for example, substance use, mental health, case management agencies)

1.

2.

3.

Additional Notes: (e.g., times available)

RA/Data Collector : _______________________________

Date:

Contact Data Form Rev. 1-17-08

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