Formative - Developmental

LOI2-PHYS-01 EXEMPLAR CONTACT INFORMATION SHEET ATTACHMENT C.3.4

OMB Number: 0925-0593

Expiration Date: July 31, 2013

LAST NAME: _______________________________ STUDY ID: __ __ __ __ __

FIRST NAME / M.I.: __________________________ DATE: __ __ / __ __ / __ __ (dd/mm/yy)

DATE OF BIRTH: __ __ / __ __ / __ __ (dd/mm/yy) INTERVIEWER: __ __

CONTACT INFORMATION

“This information will allow us to contact you during the study. It is important that we have several ways to reach you in case one or more of them don't work (for example, cellphones can get disconnected, etc). ALL INFORMATION THAT YOU GIVE WILL BE KEPT CONFIDENTIAL”.

Primary address: (this is the address where the child participating in the study lives)

Street and number: ______________________________________

City and zipcode: ________________________ / __ __ __ __ __

Backup address: (secondary address where we can contact you or a relative or friend)

Street and number: ______________________________________

City and zipcode: ________________________ / __ __ __ __ __

Who lives here: ________________________ / ____________ (name and relationship)

Telephone numbers:

Primary: ( __ __ __ ) - __ __ __ - __ __ __ __  Cellphone  Landline

Belongs to: ____________________ / ____________ (name and relationship)

Backup 1: ( __ __ __ ) - __ __ __ - __ __ __ __  Cellphone  Landline

Belongs to: ____________________ / ____________ (name and relationship)

Email address:

Primary: ______________________________

Belongs to: ____________________ / ____________ (name and relationship)

Backup 1: ______________________________

Belongs to: ____________________ / ____________ (name and relationship)

Pediatrician:

Name: ______________________________

Phone: ( __ __ __ ) - __ __ __ - __ __ __ __

Public reporting burden for 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 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.