Locator Forms by Site

Development and Testing of an HIV Prevention Intervention

Targeting Black Bisexually-Active Men

Attachment 3B

Locator Forms by Site

Form Approved:

OMB No. 0920-XXXX

Expiration Date:

3B.1: PHMC: Locator Form

(Interviewer: Read the following introduction to the participant)

It is important that you and the survey staff remain in regular contact. It is also important for your counselor to know how to contact you in case of a missed appointment or if an appointment needs to be rescheduled. This interview is designed to help you and the study staff determine how we will locate you for the next three months.

We ask for a lot of locator information- names, addresses, phone numbers- that may help us find you to remind you of your next appointment. We do this because we want to make sure we can find you when it is time for your next interviews. We understand that you may not have information to answer all the questions, but we ask that you give the best information you have so we can easily contact you to remind you about your next appointment.

We understand that this is very private information and take a lot of care to protect it. This information is available only to the Connections Team so we can call you or send you a message about your next visit. The information is kept in locked files. These files are separate from those used to store other data, which are labeled by an ID number only. Information we store in the computer can only be accessed by using a special password.

It is very important that you give us accurate information. If there's something you don't want to answer, it would be better if you said "I don't want to answer that", rather than tell us something that's not true.

When we send letters or leave phone messages, we don't reveal your personal information. We just say that we're calling or writing from the Connections Program. If you would prefer us to say or write something else, please let us know and we'll note it in our records. If you belong to any social networking sites, such as MySpace or Facebook and provide us with your member information, we will only contact you through personal messaging. Please remember that you are not required to provide this information, but the information you give us is very helpful to our project.

Primary Contact

1. Name: __________________________________ 1a. Nickname/Street name:

2. Month and year of birth _______/ ________

3. What is the address where you currently live or stay? APT#

Parents Family Shelter Homeless Best mailing address (if checked skip q# 7)

City State ZIP _________ Phone ,

Best contact # Best contact # (if checked skip q#8)

4. Best time to call & at which number(s):

5. Who lives at this address with you? (enter names & relationship to Participant)

Person’s Name Relationship

2^nd Primary Contact or Secondary Contact (these are people you have regular contact with)

Contacts Like:

1. Friends 2.Doctor Office 3.Welfare Caseworker 4.Shelter 5.Family 6.Lawyer 7.Study Participant 8.Neighbor

6. Name Relationship

Address ___________________________________ APT# _______ City ZIP ______________ Phone ____________ ,

What name does this contact call you? When was your last contact with this person?

Secondary Contact (these are people you have regular contact with)

6a. Name Relationship

Address ___________________________________ APT# _______ City ZIP ______________ Phone ____________ ,

What name does this contact call you? When was your last contact with this person?

Secondary Contact (these are people you have regular contact with)

6b. Name Relationship

Address ___________________________________ APT# _______ City ZIP ______________ Phone ____________ ,

What name does this contact call you? When was your last contact with this person?

7. What is the best mailing address to contact you at over the next 3 months? (skip: if best mailing address above)

Address: APT# ________City, State: Zip______________

Who lives there? (enter name(s) & relationship to participant)_____________________________________________

8. What is the best phone # to contact you at over the next 3 months? (skip: if best contact # above)

Phone # Whose phone # is this? Best day/time to call

9. Do you have an email address that only you have access to? Yes  No 



if yes:_________________________________

10. Are you a member of Myspace? Yes  No 

If yes: Can we send you a message through your MySpace page? Yes  No 

If yes: Myspace screen name: __________________________ and/or email __________________

11. Are you a member of Facebook? Yes  No 

If yes: Can we send you a message through your Facebook page? Yes  No 

If yes: Facebook screen name: _________________________ and/or email ___________________

12. Do you have an AIM and/or YIM account where we could contact you? Yes  No 

AIM screen name: _______________________ and/or YIM screen name: ______________________

13. Are you presently working? (this includes part-time or occasional jobs, & “under the table” work)

 yes  no If yes: could we leave messages at your place of work?  yes  no

Address of place of work:

Phone Number: What name do they know you by:

(For follow-up visits only)

How did we get in contact with you this time? (mail, phone, home visit, etc.)

(if contacted by letter, at which address did participant receive letter):

Address:

Name of Person who resides at the above address:

Phone # Connected with above address:

Who do you know that is also participating in this study? Could we contact him/her if we have difficulty locating you?

First Name, First Initial of Last Name How is person related to you

Yes  No 

Yes  No 

Yes  No 

When you’re not at home or where you primarily stay where could we find you during the day or night?:

Intersection & Time you Are There Name of Place (i.e. bar , food shop, library, neighbors etc)

Time : Night

Day

Time : Night

Day

Time : Night

Day

14. Do you have a caseworker? May we contact them if we have difficulty locating you?

 yes  no  yes  no

Case workers name:___________________________ Phone #: _______________________

Program / organizations name: ________________________ Address: __________________________

Floor: _________ City: ______________ State: ______________________ Zip code: _____________

15. Do you have a support group, such as AA, NA? May we contact them if we have difficulty locating you?

 yes  no  yes  no

Support Group Contact:___________________________ Phone #: _______________________

Program / organizations name: ________________________ Address: __________________________

Floor: _________ City: ______________ State: ______________________ Zip code: _____________

Have you ever stayed at a shelter?  yes  no (if NO skip to q# 16)

Has it been within the past three years?  yes  no (if NO skip to q# 16)

If you were staying in a shelter could we send a letter or leave you a message?  yes  no

If “Yes” which one:

Name

If you needed to stay at a Shelter again which one would you go to?

Name

Do you ever use a church, mission or food line for meals? Yes  No  IF YES: where

16. Do you go anywhere for meals?? May we contact them if we have difficulty locating you?

 yes  no  yes  no

Contact name:___________________________ Phone #: _______________________

Program / organizations name: ________________________ Address: __________________________

Floor: _________ City: ______________ State: ______________________ Zip code: _____________

17. Have you ever been arrested? Yes  No  (if NO skip to q# 19)

18. What aliases or other names might you use if you were arrested and/or incarcerated?

19. If you were arrested, detained or incarcerated whom would you contact?

Person’s Name: Relationship to you: Phone #

Address: City: Zip:

Any other places I could call and leave a message or send a letter?

Notes or other Comments:

THANK YOU FOR YOUR TIME AND HELP.

Form Approved:

OMB No. 0920-XXXX

Expiration Date:

3B.2 NOVA: Locator Form

Instructions: This form should be completed by a staff member with the help of the participant. Tell the participant: “The information you provide will help us get in touch with you later. This information is only to help us find you so that we can confirm or schedule an appointment.”

1. Name ______________________________________________________________________

First Middle Last

2. What do your friends/acquaintances call you? _______________________________________

3. Address: ______________________________________________________________ _____________

Street Address Apt. #

___________________________________ ______________ _________________

City State Zip Code

4. E-mail addresses: 1) ___________________________________

2) ____________________________________

5. Home Telephone Number: Can we leave a message?

Yes No

6. Work Telephone Number: Can we leave a message?

Yes No

7. Cell Phone Number: Can we leave a message? Yes No

8. Can we leave a text message on your cell phone? Yes No

9. How do you prefer to be contacted? (Circle the # of your preference 4-8 on this page)

10. Best times to call:

Su M T W Th F S Between |_____|_____| : |_____|_____| a.m./ p.m. and |_____|_____| : |_____|_____| a.m./ p.m.

Su M T W Th F S Between |_____|_____| : |_____|_____| a.m./ p.m. and |_____|_____| : |_____|_____| a.m./ p.m.

Su M T W Th F S Between |_____|_____| : |_____|_____| a.m./ p.m. and |_____|_____| : |_____|_____| a.m./ p.m.

11. If someone besides you answers the phone, what should we say?

_______________________________________________________________________

12. What message (if any) should we leave on voicemail?

____________________________________________________________________________

13. May we send you items through the mail, such as reminder cards?

Yes No

Form Approved:

OMB No. 0920-XXXX

Expiration Date:

3B.3 CSU: Locator Form

On this form we collect information that will help us reach you. The information you give us will be kept in a separate place from your answers on the interview. It will be used only to locate you for study-related activities, and it will not be given to anyone else. We will not tell any contact person anything about you, except that you are participating in a health study.

1. Please tell me your full name:

_________________________/___/_________________________________

First Middle Initial Last

2. Nickname(s): ________________________

3. Month/Day/Year of birth: ________/_______/________

4. Where were you born? _____________________________________

(City, State)

5. How long have you lived in your neighborhood?________________

6. Residence Address

______________________________________________________________________________

Street Address Apt #

City State Zip Code

7. Who else lives there?

Full Name: ____________________________________________________________________

(First, Middle, Last) (Relationship)

Full Name: __________________________________________________________________

(First, Middle, Last) (Relationship)

8. How long have you lived there? _______________________

9. Do you plan to move anytime soon? ___________________________________________________

Do you know where to? ________________________________________________________________

10. Primary Phone: (______) _________________

Is this one of the following? Cell Number _____________ Home Number ___________

Best time to call this number (circle one) Morning Afternoon Evening Anytime

Ok to leave message on answering machine (circle one) Yes No

11. Alternate Number: _____________________

Is this one of the following? Cell Number _____________ Home Number ___________

Best time to call this number (circle one) Morning Afternoon Evening Anytime

Ok to leave message on answering machine (circle one) Yes No

12. Any Other number: _______________________________________________

13.Work phone? (_____) _______ ________________________________________________

(Name of Company)

14. Do you have a number where you can receive messages? (_______) __________________

15. Who lives there?

Full Name: ___________________________________________________________________

(First, Middle, Last) (Relationship)

Full Name: ___________________________________________________________________

(First, Middle, Last) (Relationship)

16. Address of the place where you can receive messages:

__________________________________________________________________________

(Street address) (Apt. # or P.O. Box)

___________________________________________________

(City) (Zip)

17. Best mailing address: _______________________________________________________________

(Street address) (Apt. # or P.O. Box)

_______________________________________ ______________________

(City) (Zip)

18. Who lives there?

Full Name: ___________________________________________________ _______________

(First, Middle, Last) (Relationship)

Full Name: ___________________________________________________ _______________

(First, Middle, Last) (Relationship)

19. Do you have an E-mail address? (Circle one) Yes No

If YES can you please provide: _____________________________

20. Do you have a website/Facebook/MySpace page (etc.)

If YES can you please provide: ____________________________ __________________________

21. Best Contacts: Do you have friends who usually know how to reach you if you should move or leave the program? Please include information about friends who may not live in Los Angeles, but will still be able to help us reach you. (If you are currently on parole or probation you may also use your Parole/Probation Officer as a contact.)

(1)

Name

Phone Alternate Number

Relationship Best time to call

(2)

Name

Phone Alternate Number

Relationship Best time to call

(3)

Name

Phone Alternate Number

Relationship Best time to call

Now I’d like to ask you about your family. If you don’t know their addresses, just the towns would help. (Complete entire family; use extra space if necessary. Don’t forget brothers, sisters, spouse, ex-spouse, girlfriend, boyfriend, baby’s father/mother, grandparents, cousins, aunts, uncles, foster parents, God parents, and adult children. Include cell phone and pager numbers.)

22. Mother: __________________________________________________________________________

(Full Name: First, Middle, Last)

______________________________________________________________________________(Address)

Phone: (_____) __________________ In touch& how often?_______________

Other phone/ contact info? (_____) ___________________________ _____________________

(Whose phone is this?)

23. Father: ___________________________________________________________________________

(Full Name: First, Middle, Last)

______________________________________________________________________________(Address)

Phone: (_____) __________________ In touch & how often? ______________

Other phone/ contact info? (_____) ________________________________________________

(Whose phone is this?)

24. Relative#1: _________________________________________________________________________

(Full Name: First, Middle, Last)

______________________________________________________________________________(Address)

Phone: (_____) __________________ In touch & how often? _____________

Other phone/contact info? (_____) ___________________________ _____________________

(Whose phone is this?)

25. Relative #2: _________________________________________________________________________

(Full Name: First, Middle, Last)

______________________________________________________________________________ (Address)

Phone: (_____) __________________ DOB: __________________ In touch? _______

Other phone/contact info? (_____) ____________________________ _________________

(Whose phone is this?)

26. Relative #3: _________________________________________________________________________

(Full Name: First, Middle, Last)

_____________________________________________________________________________________(Address)

Phone: (_____) __________________ In touch & how often? _____________________

Other phone/contact info? (_____) _________________________________________________

(Whose phone is this?)

27. Is there a case worker, doctor, community clinic, religious institution or other contact that you see or visit regularly?

Name: ______________________________________________________________________________

Address: _____________________________________________________________________________

Phone? (_____) ____________________________ Agency: ____________________________

Other phone/contact info? (_____) ___________________________ _____________________

(Whose phone is this?)

______________________________________________________________________________

28. Do you receive money or food stamps from an agency or go to a food bank regularly?

_______ Yes _______ No (If yes) Agency __________________________________________

When do you receive your food stamps? _______________________________________

Where do you receive them? __________________________________________

Who is your Case worker: __________________________________________

File #: _________________________

Who is your Representative Payee? ________________________________________________________

Phone? (_____) ____________________________

Agency: ____________________________________

29. Is there any place you go regularly to hang out or to meet with friends (e.g., coffee house, liquor store, basketball court, gym)?

Place(s): ____________________________________________________________________________

Address or Intersection:_________________________________________________________________

Phone: (_____) ___________________________

Phone: (_____) _______________________________

Times you might be there: _______________________________________________________________

30. INTERVIEWER: IF RESPONDENT (R) IS HOMELESS, OR HAS OFTEN BEEN HOMELESS, GET INFORMATION ON:

Shelters, SRO hotels: which ones does R tend to use? Where did R sleep last night?

______________________________________________________________________________

What soup kitchen, restaurant, etc. does R like to use? Where did R eat today, yesterday?

______________________________________________________________________________

Does R stay in different places in the winter vs. summer? Get list.

______________________________________________________________________________

Where does R hangout or like to buy things like liquor, coffee or other items? (Store owners who give credit may know where R tends to hang out.)

Place(s): ______________________________________________________________________________

Location(s):____________________________________________________________________________

Does R know any service workers in the area R usually hangs out? Get agency and names.

______________________________________________________________________________

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