Form Tab 10 Tab 10 Contact/Location Information Form

Tab 10

CONTACT/LOCATOR INFORMATION FORM (Phase 2 Study)

Contact Information for Tracking Enrolled Participants

THIS INFORMATION IS CONFIDENTIAL. IT WILL BE KEPT IN A LOCKED FILE AND WILL BE DESTROYED UPON COMPLETION OF THIS PROJECT.

Only Retention project staff will have access to your contact information.

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

Interview Date: ___/___/______ (MM/DD/YYYY)

Participant Study ID Number
Participant Medical Record 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? Is it OK for one of the Retention Specialists to make a visit to your home if we don’t see you at clinic for awhile?	Street:______________________________ Apt. #:______________________________ City: ______________________________ Zip Code:___________________________ Yes, it is OK No, it is not OK 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 voicemail message for you at this number? Is it OK to leave a message with anyone that might answer the phone 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 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 voicemail message for you at this number? Is it OK to leave a message with anyone that might answer the phone 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 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
Is there a person at a local community-based organization or AIDS service organization who always knows how to reach you? Is it OK to call this person and ask how to reach you? Is it OK to write to this person and ask how to reach you?	Agency name:________________________ ___________________________________ Contact person:_____________________ Relationship:_______________________ Address:___________________________ City:_______________________________ Zip Code:___________________________ Office Phone#:______________________ Cell Phone #:_______________________ Yes, it is OK No, it is not OK Yes, it is OK No, it is not OK