Tracking Form

Evaluating the Quality of Interview Data Collected by Teratology Information

Services About Pregnancy Outcomes, Maternal and Infant Health,

Following Medication Use During Pregnancy and Lactation

09/03/09

APPROVED

OMb# __0920 -XXXX__________

omb exp. date____/____/_____

ATTACHMENT C1c: TRACKING FORM

This telephone script is to be used to obtain information for contacting callers to explain the study before enrolling and to update information for contacting participants for their next interview.

Name of Caller/Participant: ___________________________________________________

Note: Read only the wording that appears in regular font when conducting the interview. Wording in italics contains instructions to the interviewer and should not be read.

If you are explaining the study to a caller for the first time, say:

When is the best time for <me/the study coordinator> to contact you?

Go to date and Time below.

If you are scheduling an interview for a study participant, say:

When is the best time for me to contact you?

Date or day of the week ____________________________________________________

Time of day or evening ____________________________________________________

What is the best phone number to use to reach you? _________________________________

Are there other phone numbers that we could use to reach you? (List as many as apply) ___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Are there any email addresses that we could use to contact you if we can’t reach you by phone?

(List as many as apply) ________________________________________________________

___________________________________________________________________________

Thank you. <I/the study coordinator> will call you. Goodbye.

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 Information Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

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