Locator Form (UNCG)

HIV/AIDS Risk Reduction Interventions for African-American

Heterosexual Men

0920-10CM

Attachment 3f

Data Collection: Locator Form – UNCG

Form Approved

OMB No. 0920-XXXX

Exp. Date XX/XX/20XX

HIV/AIDS Risk Reduction Interventions for African-American

Heterosexual Men: Locator Form – UNCG (Attachment 3f)

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)

Keep In Touch Form (KIT FORM)

We want to keep in touch with you!

We are going to ask you now to give us your name and best contact- address, phone number, and email address. Please know that we will only use this information to contact you regarding the follow up survey. Your personal information will not be linked or stored with your survey responses.

I agree to the above paragraph. Please indicate your email address as your signature.

________________________________________________________________

Signature

Name __________________________________________________________________________________

First MI Last

May we contact you by mail? Y N

Preferred Address: _____________________________________________________________________________

Address Apt. #

_____________________________________________________________________________

City State Zip

Other Address: _____________________________________________________________________________

Address Apt. #

_____________________________________________________________________________

City State Zip

May we contact you by e-mail? Y N

Campus email: _____________________________ Other email: ___________________________

May we contact you by phone? Y N

Campus/Local phone: ______________________ Cell phone: ___________________________

Work phone: ______________________

Share phone? Y N Best time to call_____________________________

May we leave you a voice mail that states we are calling from the Brothers Leading Healthy Lives program? Y N

Where should we send mail? ____Preferred mailing address ____Other mailing address

May we send you emails from the Brothers Leading Healthy Lives program? Y N

Preferred contact #? Home___ Work___ Cell___ Email___