Limited Locator Form

Form Approved:

OMB No. 0920-XXXX

Expiration Date: 00/00/2014

Evaluating Locally-Developed HIV Prevention Interventions for African-American MSM in Los Angeles

Attachment 3c

Limited Locator Information

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 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 CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-New)

Form Approved:

OMB No. 0920-XXXX

Expiration Date: 00/00/2014

MyLife MyStyle

Limited Locator Information*

Name (e.g., Jeff K.)	Available for groups M T W R F Sa	Email Address	Phone #	Can we leave a message at this #?	Screen (S) Baseline app (B)
				Y N	S B
				Y N	S B
				Y N	S B
				Y N	S B
				Y N	S B
				Y N	S B
				Y N	S B
				Y N	S B
				Y N	S B
				Y N	S B
				Y N	S B
				Y N	S B
				Y N	S B
				Y N	S B
				Y N	S B
				Y N	S B
				Y N	S B
				Y N	S B
				Y N	S B
				Y N	S B
				Y N	S B

*for screening men who cannot be screened in the field and for setting baseline appointments