#1 - Tracking Survey

ID NUMBER LABEL

Early Head Start Follow-up Study

Contact Information Update

• Thank you for taking the time to update your contact information for the Early Head Start Follow-up Study.

• Please remember all the information you provide will be shared ONLY with researchers working on the Early Head Start Follow-up Study.

• If you are contacted in the future for the study, you can decide at that time whether or not to take part.

• When you are finished completing this form, please use the postage paid return envelope provided to mail it to us.

• When we receive your updated contact information, we will send you a check for $10 to thank you for your time.

• If you have any questions, please call us on the study toll-free number at:

(888) 800-3748.

Thank you!

The valid OMB control number for this information collection is XXXX-XXXX.

1. Please take a look at the names printed on the letter that came with this form. Is your name correct?

 Yes

 No  What is your correct name?

First

Middle

Last

2. Is the child’s name correct?

 Yes

 No  What is the child’s correct name?

First

Middle

Last

3. Are you still this child’s primary caregiver?

 Yes  PLEASE CONTINUE TO THE NEXT QUESTION (#4)

 No  PLEASE SKIP TO SECTION 2 (PAGE 5)

4. What is your current home address?

Street		Apt. Number
City	State	Zip Code

5. Do you receive mail at this address?

 Yes

 No  Where do you receive mail?

Street		Apt. Number
City	State	Zip Code

6. What is the best phone number to reach you on?

( _______ ) ________ --- ______________

 Cell  Home  Work  Other: _____________

7. What other phone numbers could we call you on?

( _______ ) ________ --- ______________	 Cell  Home  Work  Other: _____________
( _______ ) ________ --- ______________	 Cell  Home  Work  Other: _____________
( _______ ) ________ --- ______________	 Cell  Home  Work  Other: _____________

8. What is your email address?  Mark this box if you do not have email.

_____________________________ @ _________________________

9. If you work outside the home, where do you work?  Mark this box if you do not work outside the home.

Company Name
Street
City	State	Zip Code
Phone Number ( __________ ) ___________ --- __________________ Extension: ___________

10. What school does the child attend? What grade is the child in as of Spring 2011?  Mark this box if the child is not currently in school.

School Name

City

Grade

11. Do you have any plans to move in the next year?

 Yes  PLEASE CONTINUE TO THE NEXT QUESTION (#11a)

 No  PLEASE SKIP TO QUESTION #12

11a. If you expect to move, when do you expect to move?

^{Approximate Date of Move (Month and Year)}

11b. If you expect to move, where do you expect to move?

City

State

Country

12. In case we are unable to reach you in the future, please give us the names and contact information of three close relatives or friends who are likely to know how to contact you. We will only contact these people if we are unable to contact you directly.

1^st Contact:

First Name		Middle Initial	Last Name
Gender  Male  Female	Preferred Language  English  Spanish  Other: _____________	Relationship to You  Your parent  Your sister/brother  A friend  A former spouse  A current spouse  Someone else: _________________
Street Address					Apt. Number
City				State	Zip Code
Best Phone Number				 Cell  Home  Work  Other: ___________
( __________ ) ___________ --- ___________________
Alternate Phone Number				 Cell  Home  Work  Other: ___________
( __________ ) ___________ --- ___________________

2^nd Contact:

First Name		Middle Initial	Last Name
Gender  Male  Female	Preferred Language  English  Spanish  Other: _____________	Relationship to You  Your parent  Your sister/brother  A friend  A former spouse  A current spouse  Someone else: _________________
Street Address					Apt. Number
City				State	Zip Code
Best Phone Number				 Cell  Home  Work  Other: ___________
( __________ ) ___________ --- ___________________
Alternate Phone Number				 Cell  Home  Work  Other: ___________
( __________ ) ___________ --- ___________________

3^rd Contact:

First Name		Middle Initial	Last Name
Gender  Male  Female	Preferred Language  English  Spanish Other: _____________	Relationship to You  Your parent  Your sister/brother  A friend  A former spouse  A current spouse  Someone else: _________________
Street Address					Apt. Number
City				State	Zip Code
Best Phone Number				 Cell  Home  Work  Other: ___________
( __________ ) ___________ --- ___________________
Alternate Phone Number				 Cell  Home  Work  Other: ___________
( __________ ) ___________ --- ___________________

Thank you for the updated information. Please use the postage paid return envelope provided to mail this form to us. When we receive it, we will send you a check for $10. You should receive it in two to three weeks.

Thank you for taking part in the Early Head Start Follow-up Study!

1. Who is this child’s primary caregiver now? (What is his/her name)?

 Mark this box if you do not know.

First

Middle

Last

2. What is this person’s relationship to the child?

^{Relationship to Child}

 Parent  Non-relative foster parent

 Grandparent  Other non-relative

 Other relative  Someone else: ___________________________

3. About when did this person become the child’s primary caregiver?

^{Approximate Date (Month and Year)}

4. What is the best phone number to reach this person on?

( ________ ) ________ --- _________________

 Cell  Home  Work  Other: _________

5. Do you have any other phone numbers for this person?

( ________ ) ________ --- _________________	 Cell  Home  Work  Other: _________
( ________ ) ________ --- _________________	 Cell  Home  Work  Other: _________
( ________ ) ________ --- _________________	 Cell  Home  Work  Other: _________

6. What is this person’s email address?  Mark this box if you do not have email.

__________________________ @ _______________________

7. What is the child’s current home address?

Street		Apt. Number
City	State	Zip Code

8. What is the child’s permanent home address?  Same as current home address

Street		Apt. Number
City	State	Zip Code

9. What school does the child attend? What grade is the child in as of Spring 2011?  Mark this box if the child is not currently in school.

School Name

City

Grade

Thank you very much for your help.

If you are in contact with the child’s new primary caregiver, we’d appreciate it if you could give him/her our toll-free number:1-888-800-3748 and let him/her know we are trying to reach him/her about the study.

Please use the postage paid return envelope provided to mail this form to us. When we receive it, we will send you a check for $10. You should receive it in two to three weeks.

Thank you for taking part in the Early Head Start Follow-up Study!

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: XXXXXX