Participant Contact Information Form

Form Approved:

OMB No. 0920-0913

Expiration Date: 01/31/2015

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: _______________________________________

Nickname: ____________________

Home Address: _______________________________

City: ________________________

State: _______________________________________

Zip: _________________________

Mailing Address: ______________________________

City: ________________________

State: _______________________________________

Zip: _________________________

Home Phone: _________________________________

Work Phone:

_______________

Cell Phone: ___________________________________

Other Phone:

________________

Email Address: ________________________________

Facebook Name: _______________________________________________________________

MySpace Name: _______________________________________________________________

If participant is homeless, provide additional information below:

Shelters: ________________________________________________________________________

Eateries: ________________________________________________________________________

Liquor Stores: ___________________________________________________________________

Other list of places or contacts: ______________________________________________________

Do you receive money or food stamps regularly?

Agency: ____________________________ Case Worker: _______________________________

Location: ___________________________ When: _____________________________________

Phone Number: ______________________

Other Agency Contact Info (e.g. agency where services are received regularly)

Agency: ____________________________ Contact: ___________________________________

Location: ___________________________ When: _____________________________________

Phone Number: ______________________

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?

Work Phone

Voicemail OK?

Work Phone

Voicemail OK?

Email

Email

Letter/Postcard

Letter/Postcard

Facebook

Facebook

MySpace

MySpace

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: ______________________________

Contact information for:

Relative

Friend

Partner

Other

Name: ________________________________________________________________________

Home Phone: _______________________________

Voicemail OK?

Cell Phone: _________________________________

Voicemail OK?

Email Address: ______________________________

Regular place to hang out?

Where: _______________________________________________________________________

Address/Intersection: ____________________________________________________________

Phone Number: ________________________________________________________________

Days/Times you might be there: __________________________________________________