Locator Form (NYBC)

HIV/AIDS Risk Reduction Interventions for African-American

Heterosexual Men

0920-10XX

Attachment 3e

Data Collection: Locator Form – NYBC

Form Approved

OMB No. 0920-XXXX

Exp. Date XX/XX/20XX

HIV/AIDS Risk Reduction Interventions for African-American

Heterosexual Men: Locator Form – NYBC (Attachment 3e)

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 persons 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: OMB-PRA (0920-09XX)

Locator Form
We want to keep in touch with you

We are going to ask you now to give us your name, address and phone number, if you have one, and the names and addresses of at least 2 people who know you. We will use this information during the time you are taking part in this study to remind you of your appointments, follow-up after study visits and to contact you in case we have some information about this study that you need to know. All information will be kept private. This information can only be seen by the study staff.

• We will always try to reach you first directly. We will try by telephone and mail.

• If we are not be able to reach you directly, we will contact the people who know you whose information you give to us. We will contact them by telephone. We ask you to tell them that we may contact them in the future.

• If we cannot contact you directly or through your contact, we may make a visit to your home or to a contact’s home.

• You may refuse to answer any question on this form. However, to be eligible for the study we need your contact information and that of at least 2 people who know you.

Remember that all of this information is confidential.

1. Name: ___________________________________________ _____ ________________________________ First MI Last

Nick Name (s): _______________________________________________

2. Age: _____ Date of Birth: ______/______/19_____

 Verified Type of Document: _______________________

3. Where do you currently live?

Address ____________________________________________________

____________________________________________________ Apt No.: _______

City ________________________________ State___________ Zip Code: _______

Type of dwelling: ______________________________________________________

Whose place is it? ______________________________________________________

Name Relationship

Yes  (skip to Q5)

No  (complete address below)

4. Is this the best place to send mail?

Address: _________________________________________________

_________________________________________________ Apt No.: _______

City_______________________________ State___________ Zip Code: _______

5. May we send you: Appointment reminders?  Yes  No

Project updates  Yes  No

and general mailings?  Yes  No

6. Daytime phone number: (______)______________________ ext. ______

Evening phone number: (______)______________________ ext. ______

Cell phone number: (______)______________________

If we leave a message for you, what can we say?

Project ACHIEVE q Health clinic q Friend q

Other: q _____________________________________________________________

Email: _________________________________________________________________

7. What is the best way to leave you reminders about your appointments for study visits?

   1. q Phone (specify: _________________________) Text message? qYes q No

   2. q Mail

   3. q Other (specify: ______________________________________________)

d. q E-mail (specify: _____________________________________________)

7. Which of the above is the best way to reach you quickly, if necessary?

Specify: _______________________________________________

7. May we contact you at work? q Yes q No q not working

Name of employer: ________________________________________________

Work Address: ________________________________________________________

City: ___________________________ State: ______ Zip: _________

Phone: ___________________________________

Can we leave a message at this number? q Yes q No

If yes, what can we say?

Project ACHIEVE q Health clinic q Friend q

Other: q ___________________________________________________

SECONDARY CONTACT INFORMATION: Parent, sister/brother, other relative, good friend, neighbor, case worker/social worker or counselor. If not in contact with the person within the last month, ask for another contact.

CONTACT #1

7. Name: _________________________________  Refuse to provide

Address: __________________________________________________________________

Phone: (______)__________________________

What is your relationship to this person? ____________________________

When did you last see or hear from this person? ______/______/_____

If we leave a message with them for you, what can we say?

Project ACHIEVE q Health clinic q Friend q

Other: q _____________________________________________________________

CONTACT #2

7. Name: _________________________________  Refuse to provide

Address: __________________________________________________________________

Phone: (______)__________________________

What is your relationship to this person? ____________________________

When did you last see or hear from this person? ______/______/_____

If we leave a message with them for you, what can we say?

Project ACHIEVE q Health clinic q Friend q

Other: q _____________________________________________________________

OTHER INFORMATION ABOUT YOU

7. Is there a neighbor we could leave a message with  Yes  No

if we visit your home and you are not there?

What is his/her name and address?

Name: _________________________________ Relationship: ________________

Address:______________________________________________________________________

7. What are the last four digits of your social security number? ________  Refuse to provide

7. Type of Photo ID shown:

 Driver’s license

 State ID for __________________

 Welfare/Food Stamp ID

 Job ID

 Other: _______________________

15. Photocopy attached?  Yes  No

We will keep this completed form on file for the duration of the study.

We would also like to keep this information on file after this study so we may contact you future studies. Agreeing to be contacted about future studies does not mean that you have agreed to take part in any future studies or that you will be eligible for any future studies. At the time of those studies, you will be free to choose whether or not to participate, if eligible. If at any time after this study, you do not want us to contact you, you may refuse at any time.

16. May we keep this information on file after this study so we may contact you about future studies?

 Yes  No