Brief Locator Information

Form Approved:

OMB No. 0920-xxxx

Expiration Date: xx/xx/xxx

Critical Thinking and Cultural Affirmation (CTCA): Evaluation of a Locally Developed HIV Prevention Intervention

Attachment 5

Brief Locator Information Form

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)

Brief Locator Information Form

Place of Contact:_________________________________________________

Intervention Staff Name: ___________________________________________

Date: ___/ ___/ ___

1. Name: _________________________ ________ _________________________

Last MI First

2. What is your preferred method of contact for the twice monthly men’s health messages that, upon your reply, automatically enter you in a raffle to win a $150, $50, or $25 prize? (Check all that apply.)

• Phone – voice message  Facebook message (private)

• Text message  Twitter message (private)

• E-mail  Other: __________________

• Mail

3. What is your preferred method of contact for appointment reminders and other study-related communication? (Check all that apply.)

• Phone – voice message  Facebook message (private)

• Text message  Twitter message (private)

• E-mail  Other: __________________

• Mail

4. Daytime phone number: (________) _______________________

Evening phone number: (________) _______________________

Cell phone number: (________) _______________________

Electronic (e-mail, Facebook, Twitter) preferred contact _____________________________

May we send a text to your phone?  Yes  No