Minnesota Contact Information

Study ID

Form Approved

OMB No. 0923-XXXX

Exp. Date xx/xx/20xx

Attachment 5d. (MN 10.1)

Contact Information Form

Script: We need up-to-date information about how to reach you so we can send you the results of tests done on your blood and urine samples. We won’t use this information for any other purpose. Would you please verify, update or correct what I have.

Show or read the information provided to participant. Ask them if the information is correct. If they indicate the information is correct, check the verified/confirmed box. Ask them to tell you how to correct any item that is incorrect; make the corrections and check the changed box. If no information is already given, ask the optional probe question and record their answer.

1. Is this your correct full name? Optional Probe if none supplied: What is your full name?

First: _________________________

Last: _ _______________________

Middle initial:__________________

[ ] verified/confirmed

[ ] changed

[ ] Refused

2. Is this your correct email address?

Email: _________________________

[ ] verified/confirmed

[ ] changed

[ ] Refused

Optional Probe if none supplied: Do you have an email address? Prompt: We will only use this if we have trouble mailing your results to you.

[ ] Yes (if checked, go to 2a)

[ ] No

[ ] DK

[ ] Refused

2A. (If YES) What is it?________________________________

Public reporting burden of this collection of information is estimated to average 2 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0923-XXXX).

3. Is this your correct phone number?

Phone: _________________________

[ ] verified/confirmed

[ ] changed

[ ] Refused

Optional Probe if none supplied: Do you have a phone number where we can reach you? Prompt: This can even be the number of a friend, relative or someone who will know how to find you if you move.

[ ] Yes (if checked, go to 3A)

[ ] No

[ ] DK

[ ] Refused

3A. (if YES) What is it? Additional Prompt: Are there any other numbers that could help us find you if you move.

Phone:_______________________________  Home  Work  Cell  Other

Phone:_______________________________  Home  Work  Cell  Other Phone:_______________________________  Home  Work  Cell  Other

4. Is this your correct street address? Optional Probe if none supplied: What is your street address?

Street Number: _ _____ Street Name:__ _________________ Unit: _ _________

City: _______________ __________ State: __MN____ ZIP Code: ______________

[ ] verified/confirmed

[ ] changed

[ ] None

[ ] Refused

5. Is this on the Fond du Lac Reservation?

[ ] Yes

[ ] No

[ ] DK

[ ] Refused

6. Is your mailing address different from your street address?

[ ] Yes (if checked, go to 6A)

[ ] No

[ ] DK

[ ] None

[ ] Refused

6A. (if YES to Q 6) What is your mailing address?

Street Number: _ _____ Street Name:__ _________________ Unit: _ _________

City: ______________________State: _______ ZIP Code: ______________

[ ] DK

[ ] Refused

7. Is this your correct birthdate? Optional Probe if none supplied: What is your birthdate?

_____ / / .

mm dd yyyy

[ ] verified/confirmed

[ ] changed

[ ] DK

[ ] Refused

Date:___________________________ Interviewer Name:__________________________

Appendix 10.1 page 5