Form Approved:
OMB No. 0920-xxxx
Expiration Date: xx/xx/xxxx
Critical Thinking and Cultural Affirmation (CTCA): Evaluation of a Locally Developed HIV Prevention Intervention
Attachment 7
Record Locator 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)
PID:____________
Date: ___/ ___/ ___
Loyola Univesity Chicago
820 N. Michigan
Chicago, IL 60611
We are going to ask you now to give us your name, address, and preferred contact information, in addition to the names and addresses of at least 2 people who know you. We wil use this information during the time you are taking part in this study to remind you of your appointments, follow up after study visits and to contact you in case we have some information about this study that you need to know. Additionally, we will be sending you men’s health and wellness messages up to twice per month. By replying to these messages, you will be automatically entered into a raffle for one of the $150, $50, or $25 prizes.
All information will be kept private. This information can only be seen by study staff.
We will always try to reach you first directly. We will try by telephone, mail, e-mail, text message, Facebook message, Twitter message, etc. – whichever method you prefer.
If we are not able to reach you directly, we will contact the people who know you whose information you gave to us. We will contact them by telephone. We ask you to tell them that we may contact them in the future. Please note that if we contact them, we will only refer to this study as the “CTCA Program”.
If we cannot contact you directly or through your contact, we may make a visit to your home or to a contact’s home.
You may refuse to answer any question on this form. However, for follow-up study visits we need your contact information and that of at least 2 people who know you.
We will keep this completed form on file for the duration of the study. After the study is completed, we will destroy the record.
Remember that all of this information is confidential. Please discuss any concerns or questions you may have with study staff.
Recruitment Location: _______________________________________ Date: ____/ ____/ ___
Participant Name: ____________________________ Staff Initials: ___________ Date: ____/ ____/ ____
PID:____________
Date: ___/ ___/ ___
Name: _________________________ ________ _________________________
Last MI First
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: __________________
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: __________________
What is the best way to reach you quickly if necessary? (Check all that apply.)
Phone – voice message Facebook message (private)
Text message Twitter message (private)
E-mail Other: __________________
Participant Name: ____________________________ Staff Initials: ___________ Date: ____/ ____/ ____
PID:____________
Date: ___/ ___/ ___
Where do you currently live?
Address: ___________________________________________________________
_______________________________________________________ Apt. #: ______
City: ________________________ State: ______________ Zip Code: __________
Type of Dwelling: _____________________________________________________
Whose place is it? ____________________________________________________
Name Relationship
Is this the best place to send postal mail (e.g., appointment reminder cards)?
Yes (Skip to question 7.) No (Complete address below.)
Please provide an alternate postal address:
Address: ___________________________________________________________
_______________________________________________________ Apt. #: ______
City: ________________________ State: ______________ Zip Code: __________
May we mail you: Appointment reminders? Yes No
Project updates? Yes No
General mailings? Yes No
Daytime phone number: (________) _______________________
Evening phone number: (________) _______________________
Cell phone number: (________) _______________________
May we send a text to your phone? Yes No
Participant Name: ____________________________ Staff Initials: ___________ Date: ____/ ____/ ____
PID:____________
Date: ___/ ___/ ___
If we leave a voice or text message for you, who should we say it is from? (Check all that apply.)
Loyola University Chicago
CTCA Study
Friend
Other: _______________________________________________
10. On a normal week day, where can we find you or where do you hang out at 9:00 am?
_________________________________________________________________
11. On a normal week day, where can we find you or where do you hang out at 5:00 pm?
_________________________________________________________________
12. May we visit you at your current address if we are not able to reach you by phone, text or e-mail?
Yes No
13. If we visit your home and you are not there, is there a neighbor we could leave a message with that simply asks you to contact the CTCA study?
Yes No
What is his/her name and address?
Name: _______________________________________________
Address: ___________________________________________________________
_______________________________________________________ Apt. #: ______
City: ________________________ State: ______________ Zip Code: __________
Phone: _________________________
Participant Name: ____________________________ Staff Initials: ___________ Date: ____/ ____/ ____
PID:____________
Date: ___/ ___/ ___
SECONDARY CONTACT INFORMATION
Please give us two people who know you and who you would be comfortable with study staff contacting if we cannot reach you first. This could be a parent, sister or brother, other relative, friend, neighbor, case worker/social worker or counselor, etc. This should be someone with whom you have regular contact.
Contact #1 (Emergency Contact)
Name: _______________________________________________
Address: ___________________________________________________________
_______________________________________________________ Apt. #: ______
City: ________________________ State: ______________ Zip Code: __________
Phone: _________________________
What is your relationship to this person? _______________________________
When did you last see or hear from this person? : _____/ _____/ ______
If we leave a message with them for you, who should we say it is from? (Check all that apply.)
Loyola University Chicago
CTCA Study
Friend
Other: _____________________________________________
Does this person know you are in the study and what this study is about? Yes No
Participant Name: ____________________________ Staff Initials: ___________ Date: ____/ ____/ ____
PID:____________
Date: ___/ ___/ ___
Contact #2 (Emergency Contact)
Name: _______________________________________________
Address: ___________________________________________________________
_______________________________________________________ Apt. #: ______
City: ________________________ State: ______________ Zip Code: __________
Phone: _________________________
What is your relationship to this person? _______________________________
When did you last see or hear from this person? : _____/ _____/ ______
If we leave a message with them for you, who should we say it is from? (Check all that apply.)
Loyola University Chicago
CTCA Study
Friend
Other: _____________________________________________
Does this person know you are in the study and what this study is about?
Yes No
Participant Name: ____________________________ Staff Initials: ___________ Date: ____/ ____/ ____
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Freeman, Arin (CDC/OID/NCHHSTP) |
| File Modified | 0000-00-00 |
| File Created | 2021-01-30 |