HiLo Household Inventory Questionnaire 20110420 - LOIx-QUEX-01-B

OMB #: 0925-0593

Expiration Date: 07/31/ 2013

Hi-Lo Household Inventory Questionnaire, LOIx-QUEX-01-B

Recruitment Strategy Substudy

Event Name(s):

Hi/Lo Household Inventory Script (HI, LI)

Instrument Name(s) and Versions:

Hi/Lo Household Inventory Script (HI, LI) – 1.0

Recruitment Groups:

High Intensity, Low Intensity

Househould Inventory Questionnaire Script

TABLE OF CONTENTS

OUTGOING CALLS 1

ANSWERING MACHINE 2

INBOUND CALLS 3

CAPI 4

VERBAL CONSENT TO SCREENING FOR STUDY ELIGIBILITY 4

GENERAL ELIGIBILITY QUESTIONS 5

HOUSHOLD ROSTER 8

TRACING QUESTIONS 13

SUMMARY OF ELIGIBILITY STATUS 14

Househould Inventory Questionnaire Script

PHONE SCRIPT

Outgoing calls

Hello, my name is [INTERVIEWER NAME] and I am calling on behalf of the National Children’s Study and the [LOCAL STUDY AFFILIATE].

We recently sent you a letter about the National Children’s Study. The study will examine the role of the environment on the health and development of children across the United States. The goal is to improve the health and well-being of children.

Am I speaking to an adult who lives in this household?

YES [CONTINUE]

NO [ASK TO SPEAK TO AN ADULT; WAIT FOR THEM TO COME TO THE PHONE AND REPEAT THE INTRO]

I’m pleased to inform you that your neighborhood is one of many neighborhoods in [COUNTY NAME] County selected to be part of the National Children’s Study. This means that you and others in your household might be able to take part the study.

HOUSEHOLD IS RANDOMIZED TO HIQ GROUP: To get the Study under way, we need your help. I’d like to ask you a few questions to see if you or someone in your household might be able to take part in the study. It should take only a few minutes.

HOUSEHOLD IS RANDOMIZED TO HIQ INCENTIVE GROUP: To thank you for your time, we are offering a drawing for either a $50 savings bond or a $25 gift card for [STORE NAME]. You can choose to be a part of this drawing whether or not you or anyone in your household participates in the study. One hundred individuals will be selected for the bonds or gift cards, and they will be notified around February 2011.

PROCEED TO HIQ

ANSWERING MACHINE

Hello, this is [INTERVIEWER NAME] with the National Children’s Study and the [LOCAL STUDY AFFILIATE]. We would like to speak to you about an important study that is taking place in {STUDY CENTER’S COUNTY]. I’m sorry that we’ve missed you. We’ll try to contact you again soon. Of course, you can always speak with someone about the Study by calling our toll-free number at [TOLL-FREE NUMBER]. That number again is [TOLL-FREE NUMBER]. Thank you. We look forward to talking with you.

INBOUND CALLS

Hello, thank you for calling the National Children’s Study and the [LOCAL STUDY AFFILIATE]. My name is [INTERVIEWER NAME]. How may I help you?

{CALLER SAYS THAT THEY RECEIVED A MAILING FROM US}

I would like to look up your information in our database. Could you give me the identification number printed on your letter?

{If caller doesn’t have Identification number, ask} Can you please tell me your address?

[IF PARTICIPANT IS NOT IDENTIFIED] Thank you. I am not able to locate your address/identification number in our database. I would like to follow-up on this and call you back. At what number can I reach you?

[IF PARTICIPANT IS IDENTIFIED] Thank you.

HOUSEHOLD IS RANDOMIZED TO HIQ GROUP: To get the Study under way, we need your help. I’d like to ask you a few questions to see if you or someone in your household might be able to take part in the study. It should take only a few minutes.

HOUSEHOLD IS RANDOMIZED TO HIQ INCENTIVE GROUP: To thank you for your time, we are offering a drawing for either a $50 savings bond or a $25 gift card for [STORE NAME]. You can choose to be a part of this drawing whether or not you or anyone in your household participates in the study. One hundred individuals will be selected for the bonds or gift cards, and they will be notified around February 2011.

PROCEED TO HIQ

Household Inventory Questionnaire

CAPI

INSTRUCTIONS TO INTERVIEWER: Questionnaire and other required text is shown in regular font. Interviewer instructions and text not to be read to respondents is shown in ALL CAPS. Introductory text that may or may not be appropriate for all recruitment strategies is shaded. Variable names are shown in BOLD CAPS.

Verbal Consent To Screening For Study Eligibility

(HH_INCENTIVE)HOUSEHOLD IS RANDOMIZED TO HIQ INCENTIVE GROUP: Would you like to be included in the drawing for a $50 savings bond or $25 [STORE NAME] gift card?

YES…………………………………………………………………………………………1

NO…………………………………………………………………………………………..2

(TIME_STAMP_1). PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

AD003. (HH_MEMBER) Are you a member of this household (and at least [LOCAL AGE OF MAJORITY])? SKIP THIS QUESTION IF ALREADY ANSWERED AS PART OF THE OUTGOING CALL.

YES…………………………………………………………………………………………1

NO…………………………………………………………………………………………..2

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION: IF RESPONSE IS NOT ‘YES’ ASK TO SPEAK WITH AN ADULT HOUSEHOLD MEMBER AND RE-READ INTRODUCTION

• OUTCOME 1- IF NO ONE HOME OF LOCAL AGE OF MAJORITY OR OLDER, SAY

“Thank you for your time. When would be the best time to reach someone who lives here who is [LOCAL AGE OF MAJORITY] or older?”

General Eligibility Questions

(TIME_STAMP_2). PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

GE001. First, I’d like to make sure I have the correct address. Just to confirm, what is the address of this household?

PROGRAMMER INSTRUCTION: DISPLAY ADDRESS AS KNOWN; ALLOW INTERVIEWER TO MAKE CORRECTIONS

INTERVIEWER INSTRUCTION: CONFIRM ADDRESS IF R PREVIOUSLY STATED IT.

ADDRESS 1 (ADDRESS_1)

• STREET NUMBER

• PRE-DIRECTIONAL

• STREET NAME

• STREET TYPE

• POST DIRECTIONAL

ADDRESS 2 (ADDRESS_2)

UNIT (UNIT)

• UNIT TYPE

• UNIT NUMBER

CITY (CITY)

STATE (STATE)

ZIP CODE (ZIP)

ZIP+4 (ZIP4)

REFUSED -1

DON’T KNOW -2

• IF THE RESPONDENT REFUSES TO ANSWER THE ADDRESS QUESTION, DESCRIBE HOW HIS/HER ELIGIBILITY IS DETERMINED BY HIS/HER RESIDENTIAL ADDRESS AND THAT ALL DATA ARE KEPT CONFIDENTIAL AND SECURE. IF RESPONDENT STILL REFUSES, END THE INTERVIEW AND CODE AS A REFUSAL.

• IF RESPONSE IS ‘DON’T KNOW’, ASK TO SPEAK WITH ANOTHER ADULT HH MEMBER WHO KNOWS. IF CANNOT FIND ANOTHER ADULT WHO KNOWS, SELECT DON’T KNOW.

GE002. (PRIVATE) Is this a private residence?

INTERVIEWER INSTRUCTIONS: DO NOT CONSIDER GROUP QUARTERS TO BE A PRIVATE RESIDENCE.

YES 1 (TIME_STAMP_4)

NO 2

REFUSED -1

DON’T KNOW -2

(TIME_STAMP_3). PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

GE003. (PLACE_TYPE) What type of place is this?

SENIOR LIVING……………………………………..1 (TIME_STAMP_10); SET (HH_ELIG) = 4

MILITARY BARRACKS…………………………….2 (TIME_STAMP_10); SET (HH_ELIG) = 4

RELIGIOUS QUARTERS…………………………..3 (TIME_STAMP_10); SET (HH_ELIG) = 4

ON-CAMPUS STUDENT HOUSING……………..4 (TIME_STAMP_10); SET (HH_ELIG) = 4

CORRECTIONAL FACILITY……………………….5 (TIME_STAMP_10); SET (HH_ELIG) = 4

HOMELESS SHELTER……………………………………………………………………….6

GROUP HOME FOR MENTALLY ILL/DEVELOPMENTALLY DISABLED……………..7

JOB CORPS HOUSING………………………………………………………………………8

DOMESTIC VIOLENCE SHELTER………………………………………………………….9

HALFWAY HOUSE…………………………………………………………………………...10

PRIVATE RESIDENCE…………………………………………………….11 (TIME_STAMP_4)

OTHER…………………………………………………………………..-5 (PLACE_TYPE_OTH)

REFUSED…………………………………………………………………………………….. -1

DON’T KNOW……………………………………………………………………………………-2

GE003A. (PLACE_TYPE_OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

GE004. (PLACE_NAME) What is the name of this place?

INTERVIEWER INSTRUCTION: CONFIRM SPELLING.

____________________________________________________________

NAME OF GROUP LIVING QUARTERS

REFUSED -1

DON’T KNOW -2

IF THIS IS NOT A PRIVATE RESIDENCE: Thank you for your time. We are primarily talking with people in private residences right now, but we may need to call you back with questions about your facility. (TIME_STAMP_8)

IF INCLUDED IN DRAWING: If you are selected for the (bond/gift card) we will call to notify you around February of next year. Do you have any questions for me? (TIME_STAMP_8)

Household Roster

(TIME_STAMP_4). PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

HR001. (R_GENDER) Are you male or female?

MALE 1

FEMALE 2

BOTH 3

DON’T KNOW -2

HR002. (NUM_ADULT) (Including yourself,) what is the total number of adults age [LOCAL AGE OF MAJORITY] or older who live here?

[Include any persons who usually stay here but are temporarily away on business, vacation, in the hospital, on full-time active military duty or students living temporarily away from home. Do not include anyone who is in a nursing home or other institution.]

INTERVIEWER INSTRUCTION: IF REFUSED, ATTEMPT TO CONVERT. IF FAIL, SELECT REFUSED.

IF DON’T KNOW, ASK TO SPEAK WITH ANOTHER ADULT HH MEMBER WHO KNOWS. IF CANNOT FIND ANOTHER ADULT WHO KNOWS, SELECT DON’T KNOW.

|___|___|

NUMBER OF ADULTS IN HOUSEHOLD

REFUSED -1(TIME_STAMP_9)

DON’T KNOW -2

HR003. (NUM_MALE) IF MALE:[Including yourself], how/How) many men [LOCAL AGE OF MAJORITY] or older live here?

|___|___|

NUMBER OF ADULT MALES

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• IF (R_GENDER) = MALE, INCLUDE TEXT IN BRACKETS

• INCLUDE SOFT EDIT IF RESPONSE > 10; PROMPT INTERVIEWER TO CONFIRM

HR004. (NUM_FEMALE) IF FEMALE: [Including yourself, how/How] many women [LOCAL AGE OF MAJORITY] or older live here?

|___|___|

NUMBER OF ADULT FEMALES

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• IF (R_GENDER) = FEMALE, INCLUDE TEXT IN PARENTHESES

• INCLUDE SOFT EDIT IF RESPONSE > 10; PROMPT INTERVIEWER TO CONFIRM

PROGRAMMER INSTRUCTIONS: SUM OF (NUM_MALE) AND (NUM_FEMALE) SHOULD BE EQUAL TO (NUM_ADULT); IF EDIT CHECK FAILS, DISPLAY ERROR MESSAGE “NUMBER OF ADULT MALES PLUS THE NUMBER OF ADULT FEMALES SHOULD EQUAL THE NUMBER OF ADULTS IN THE HOSUEHOLD. ATTEMPT TO CONFIRM INFORMATION.”

HR006. (HH_AGE_ELIG) This study is looking at children’s health, including development before birth. We are interested in women between [LOCAL AGE OF MAJORITY] and 49. Thinking only about women ages [LOCAL AGE OF MAJORITY] to 49, [including yourself], how many women [LOCAL AGE OF MAJORITY] to 49 live here?

PROGRAMMER INSTRUCTIONS: IF (HR001) (R_GENDER) = FEMALE INSERT “including yourself”

|___|___|

NUMBER OF WOMEN [LOCAL AGE OF MAJORITY] - 49

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION: IF REFUSED, ATTEMPT TO CONVERT. IF FAIL, SELECT REFUSED.

IF DON’T KNOW, ASK TO SPEAK WITH ANOTHER ADULT HH MEMBER WHO KNOWS. IF CANNOT FIND ANOTHER ADULT WHO KNOWS, SELECT DON’T KNOW.

PROGRAMMER INSTRUCTION:

• INCLUDE SOFT EDIT IF (HH_AGE_ELIG) > 10

• INCLUDE HARD EDIT IF (HH_AGE_ELIG) > (NUM_FEMALE)

BASED ON RESPONSE, SET (NUM_AGE_ELIG) = TOTAL NUMBER OF WOMEN IN HH AGES [LOCAL AGE OF MAJORITY] – 49

(TIME_STAMP_5). PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

HR005. (PREGNANT_HH) Is anyone living in the household currently pregnant?

YES 1

NO 2 (TIME_STAMP_6)

REFUSED -1 (TIME_STAMP_6)

DON’T KNOW -2 (TIME_STAMP_6)

HR007. (NUM_PREG) You mentioned that someone who lives in the household is pregnant. How many women currently living here are pregnant?

PROGRAMMER INSTRUCTION: ASK IF (PREGNANT_HH) = YES

|___|___|

NUMBER OF PREGNANT WOMEN

REFUSED -1

DON’T KNOW -2

NO ONE IN HOUSEHOLD IS PREGNANT/NOT APPLICABLE………….-7(TIME_STAMP_6)

HR008. (P_AGE)

IF (NUM_PREG) = 1

I have a few more questions about [you/her]. This information will help us to determine whether [you/she] may be able to take part in the National Children’s Study. Thinking about the oldest pregnant woman living in the household, how old [is she/are you]? If you are unsure, please make your best guess.

IF (NUM_PREG) > 1 AND FIRST LOOP CYCLE

I have a few more questions about them. This information will help us to determine whether they may be able to take part in the National Children’s Study. Thinking about the oldest pregnant woman living in the household, how old [is she/are you]? If you are unsure, please make your best guess.

IF (NUM_PREG) > 1 AND SUBSEQUENT LOOP CYCLE

Thinking about the oldest pregnant woman living in the household, how old [is she/are you]?

|___|___|

AGE

NO ONE IN HOUSEHOLD IS PREGNANT…………………………………..1(TIME_STAMP_6)

REFUSED -1

DON’T KNOW -2

IF YOUNGER THAN LOCAL AGE OF MAJORITY OR NO ONE IN HOUSEHOLD IS PREGNANT, GO TO TIME_STAMP_6

HR009. (P_FNAME) What is [her/your] first name?

INTERVIEWER INSTRUCTION: CONFIRM SPELLING.

____________________________________________________________

FIRST NAME

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• LOOP THROUGH QUESTIONS HR008 (P_AGE), HR009 (P_FNAME), FOR THE TOTAL NUMBER OF WOMEN IDENTIFIED IN HR007 (NUM_PREG)

HR011. (AGE_ELIG_FNAME) Please think about the other women in your household who are between ages [LOCAL AGE OF MAJORITY] and 49 and who we haven’t already talked about. [Let’s start with the oldest…/Thinking about the next oldest…].

What is [her/your] first name?

INTERVIEWER INSTRUCTION: CONFIRM SPELLING.

____________________________________________________________

FIRST NAME

REFUSED -1

DON’T KNOW -2

HR012. (AGE_ELIG_AGE) How old [is she/are you]?

|___|___|

AGE

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS: IF AGE < LOCAL AGE OF MAJORITY OR > 49 DISPLAY ERROR MESSAGE; IF CORRECT VALUE IS OUTSIDE OF ELIGIBILE AGE RANGE, UPDATE (NUM_AGE_ELIG) AS APPROPRIATE

WO001. Thank you. I have recorded that there are [NUMBER] women in the household who may be able to participate in the Study.

THE TOTAL NUMBER OF NCS ELIGIBLE WOMEN SHOULD BE FILLED INTO TEXT ABOVE

INTERVIEWER INSTRUCTION: READ NAMES AND CONFIRM LISTING WITH RESPONDENT

WO002. (CONFIRM_1) This number should include all women who are age [LOCAL AGE OF MAJORITY] to 49, or are currently pregnant, who usually live here, even those who may be temporarily away, such as on business, on vacation, on active military duty, in a hospital or in school. Is this correct?

YES, ALL INFORMATION IS CORRECT…………………………………… 1

NO, THERE ARE ERRORS IN THE LISTING……………………………… 2 (CONFIRM_2)

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• ALLOW INTERVIEWER TO EDIT EACH RECORD TO CORRECT THE NAME, AGE, PREGNANCY STATUS, AND RELATIONSHIP FOR EACH IDENTIFIED WOMAN

• ALLOW INTERVIEWER TO DELETE RECORDS ENTERED IN ERROR

• ALLOW INTERVIEWER TO ADD RECORDS MISSED ORIGIANLLY

• WHEN COMPLETE, DISPLAY CORRECTED LISTING AND CONFIRM IN WO003/(CONFIRM_2) BELOW.

INTERVIEWER INSTRUCTION: READ NAMES AND CONFIRM WITH RESPONDENT AGAIN

WO003. (CONFIRM_2) Is this [LISTING] correct?

YES, ALL INFORMATION IS CORRECT…………………………………… 1

NO, THERE ARE ERRORS IN THE LISTING……………………………… 2

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION: MAKE FURTHER CORRECTIONS UNTIL COMPLETE AND ACCURATE THEN UPDATE VARIABLES AS REQUIRED:

• NUM_PREG = TOTAL NUMBER OF PREGNANT WOMEN.

• NUM_PREG_ADULT = NUMBER OF PREGNANT WOMEN [LOCAL AGE OF MAJORITY] OR OLDER

• NUM_PREG_MINOR = NUMBER OF PREGNANT WOMEN YOUNGER THAN AGE OF MAJORITY

• NUM_AGE_ELIG = TOTAL NUMBER OF WOMEN IN HOUSEHOLD AGES [LOCAL AGE OF MAJORITY] - 49

SET (HH_ELIG) BASED ON UPDATES

(HH_ELIG = 1) HOUSEHOLD INFORMANT IS ELIGIBLE FOR PREGNANCY SCREENER

• IF RESPONDENT/HOUSEHOLD INFORMANT IS AGE-ELIGIBLE OR PREGNANT AND OVER THE LOCAL AGE OF MAJORITY; SET (HH_ELIG) = 1

(HH_ELIG = 2) ONE OR MORE WOMEN IN HOUSEHOLD ARE ELIGIBLE FOR PREGNANCY SCREENER

• EXCLUDING RESPONDENT/HOUSEHOLD INFORMANT- IF (NUM_PREG_ADULT) > 1 OR (NUM_AGE_ELIG) > 1; SET (HH_ELIG) = 2

(HH_ELIG = 3) NO CURRENT HOUSEHOLD MEMBERS ARE ELIGIBLE FOR PREGNANCY SCREENER

• EXCLUDING RESPONDENT/HOUSEHOLD INFORMANT- IF (NUM_PREG_ADULT) < 1 AND (NUM_AGE_ELIG) < 1; SET (HH_ELIG) = 3

Tracing Questions

(TIME_STAMP_6). PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

TR001. I have a few more questions for you. All of your information is kept completely confidential. Would you please tell me your name?

INTERVIEWER INSTRUCTION: CONFIRM FIRST NAME IF KNOWN. IF RESPONDENT IS UNWILLING TO PROVIDE INFORMATION, ASK FOR INITIALS

_____________________ ___________________

FIRST NAME LAST NAME

(R_FNAME) (R_LNAME)

REFUSED -1

DON’T KNOW -2

TR002. (PHONE_NBR) What is the best phone number to reach you?

|__|__|__| |__|__|__| -- |__|__|__|__| (PHONE_TYPE)

ENTER PHONE NUMBER AND CONFIRM.

REFUSED ……………………………………………………………....-1 (TIME_STAMP_10) DON’T KNOW………………………………………………………… -2 (TIME_STAMP_10)

RESPONDENT HAS NO TELEPHONE/NOT APPLICABLE.….. …-7 (TIME_STAMP_10)

INTERVIEWER INSTRUCTION: IF RESPONDENT SAYS THEY HAVE NO TELEPHONE, ASK AT WHAT NUMBER THEY RECEIVE TELEPHONE CALLS

TR003. (PHONE_TYPE) Is this your home, work, cell, or another phone number?

HOME 1

WORK 2

CELL 3

FRIEND/RELATIVE 4

OTHER -5 (PHONE_TYPE_OTH)

REFUSED -1

DON’T KNOW -2

TR003A. (PHONE_TYPE_OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

Summary of Eligibility Status

(TIME_STAMP_7). PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

PROGRAMMER INSTRUCTION: DISPLAY FINAL LISTING OF ALL WOMEN ELIGIBLE TO BE ADMINISTERED THE PREGNANCY SCREENER.

INTERVIEWER INSTRUCTION: BASED ON FINAL LISTING, USE THE FOLLOWING CLOSING STATEMENTS AND DISPOSITION CASE AS APPROPRIATE.

ES001/(HH_ELIG): ELIGIBILITY CLOSING STATEMENT AND DISPOSITION CASE OPTIONS

(HH_ELIG = 1)- HOUSEHOLD INFORMANT IS ELIGIBLE FOR PREGNANCY SCREENER

ES001A. It looks like you may be able to take part in this Study. To find out, I need to ask you a few more questions.

INTERVIEWER INSTRUCTION: BEGIN ADMINISTRATION OF PREGNANCY SCREENER

(HH_ELIG = 2) - ONE OR MORE WOMEN IN HOUSEHOLD ARE ELIGIBLE FOR PREGNANCY SCREENER

ES001B. It looks like some women in this household may be able to take part in this Study. May I speak to... [NAMES OF AGE-ELIGIBLE IDENTIFIED WOMEN]?

INTERVIEWER INSTRUCTION: ATTEMPT TO COMPLETE PREGNANCY SCREENER OR SET APPOINTMENTS WITH IDENTIFIED WOMEN (OR LEGAL GUARDIAN, AS REQUIRED).

(HH_ELIG = 3) - NO CURRENT HOUSEHOLD MEMBERS ARE ELIGIBLE FOR PREGNANCY SCREENER

ES001C. Right now, there is no one here that can take part in the study. Because your address is in the study area, we may be back in touch at a later time to update your household information. Thank you for your time. IF INCLUDED IN DRAWING: If you are selected for the (bond/gift card) we will call to notify you around February of next year. Do you have any questions for me?

(HH_ELIG = 4) - DWELLING UNIT IS NOT ELIGIBLE

ES001D. Thank you for your time. There is no one here that can take part in the study. IF INCLUDED IN DRAWING: If you are selected for the (bond/gift card) we will call to notify you around February of next year. Do you have any questions for me?

INTERVIEWER-COMPLETED QUESTIONS

(TIME_STAMP_8). PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

Public reporting burden for this collection of information is estimated to average 8 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0593*). Do not return the completed form to this address.