Participant Contact Information 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 3e

Participant Contact Information Form

Public reporting burden of this collection of information is estimated to average 10 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)

MyLife MyStyle

Participant Contact Information Form

We want to call you once a month before your 3 and 6 month follow-up interviews. Please complete the following contact information so we know how to best reach you.

Contact Information:

Name:

Home Address:

City:

State:

Zip:

Home Phone:

Cell Phone:

Email Address:

Facebook Name:

MySpace Name:

What is the best way to reach you? (Check one)

If we can’t reach you by the first method, what other ways can we reach you? (Check all that apply)

Home Phone

Voicemail OK?

Home Phone

Voicemail OK?

Cell Phone

Voicemail OK?

Cell Phone

Voicemail OK?

Email

Email

Letter/Postcard

Letter/Postcard

Facebook

Facebook

My Space

My Space

Relative

Relative

Friend

Friend

Partner

Partner

Other

Other

If you checked Relative, Friend, Partner or Other, please complete the contact information for the person below.

Contact information for:

Relative

Friend

Partner

Other

Name:

Home Phone:

Voicemail OK?

Cell Phone:

Voicemail OK?

Email Address:

Contact information for:	Relative	Friend		Partner	Other
Name:
Home Phone:			Voicemail OK?
Cell Phone:			Voicemail OK?
Email Address: