Form 2i Followup/Tracking Youth

Population Assessment of Tobacco and Health (PATH) Study (NIDA)

Attachment 2i
PATH Study Data Collection Instruments:
Followup/Tracking Participant Information Form for
Youth
July 23, 2012

PID (Mini-Label)

OMB Control Number: 0925-XXXX
Expiration Date:

YOUTH Participant Information Form
If [YOUTH’S NAME] has moved or any of [HIS/HER] contact information has changed since [HIS/HER] last participated
in the Population Assessment of Tobacco and Health (PATH) study*, please give us [YOUTH’S NAME]’s new contact
information by either:

(1)
(2)

Filling out the form below and returning it using the enclosed postage-paid envelope, OR
Completing the form online at [PATH URL] (if you have a smartphone, you can scan the QR code below to
visit the website); your online password is: [PASSWORD].

As a thank you for completing this form, an additional $5 will be put on [YOUTH’S NAME]’s PATH study debit card.
(Please contact us if the card was misplaced.)
If none of [YOUTH’S NAME] contact information has changed, simply check this box:



NEW CONTACT INFORMATION FOR [YOUTH’S NAME]PLEASE PRINT CLEARLY.
NAME: __________________________________________________________________________________________
FIRST
MI
LAST
STREET ADDRESS: _______________________________________________________________________________
STREET
APT. #
_________________________________________________________________________________________________
CITY
STATE
ZIP
MAILING ADDRESS (IF DIFFERENT FROM THE STREET ADDRESS ABOVE):
_________________________________________________________________________________________________
STREET
APT. #
_________________________________________________________________________________________________
CITY
STATE
ZIP
TELEPHONE NUMBER:

HOME:|__|__|__|-|__|__|__|-|__|__|__|__|

CELL:|__|__|__|-|__|__|__|-|__|__|__|__|

WORK:|__|__|__|-|__|__|__|-|__|__|__|__|

EMAIL ADDRESS: ____________________________________________ @ __________________________________
FACEBOOK NAME: _______________________________________________________________________________
TWITTER HANDLE: _______________________________________________________________________________
OTHER SOCIAL MEDIA CONTACT INFORMATION:___________________________________________________

How would you prefer that we contact you? (Select all that apply)



HOME PHONE
EMAIL



OTHER – SPECIFY: ___________________________________________________________________________




CELL PHONE
FACEBOOK




WORK PHONE
TWITTER

* This study is sponsored by the National Institutes of Health (NIH), in partnership with the Food and Drug Administration (FDA).

[PATH QR Code]

Does [YOUTH’S NAME] anticipate moving or relocating either permanently or temporarily in the next 6 to 12
months?
 NO
 YES – WHERE?
Is [YOUTH’S NAME] currently attending a college or university?

 NO

 YES

[IF YES] What are the name and location of the college or university?
__________________________________________________________________________________________
Does [YOUTH’S NAME] have plans to attend a college or university away from this address in the next 6 to 12
months?
 NO
 YES
[IF YES] What are the name and location of the college or university?
__________________________________________________________________________________________

Thank you for your time.

Public reporting burden for this collection of information is estimated to average 8 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC
7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-XXXX). Do not return the completed form to this address.

PID (Mini-Label)

OMB Control Number: 0925-XXXX
Expiration Date:

Emancipated YOUTH Participant Information Form
If you’ve moved or any of your contact information has changed since you last participated in the Population Assessment
of Tobacco and Health (PATH) study*, please give us your new contact information by either:
(1)
(2)

Filling out the form below and returning it using the enclosed postage-paid envelope, OR
Completing the form online at [PATH URL] (if you have a smartphone, you can scan the QR code below to
visit the website); your online password is: [PASSWORD].

As a thank you for completing this form, an additional $5 will be put on your PATH study debit card. (Please contact us
if the card was misplaced.)
If none of your contact information has changed, simply check this box:



NEW CONTACT INFORMATION FOR [YOUTH’S NAME]PLEASE PRINT CLEARLY.
NAME: __________________________________________________________________________________________
FIRST
MI
LAST
STREET ADDRESS: _______________________________________________________________________________
STREET
APT. #
_________________________________________________________________________________________________
CITY
STATE
ZIP
MAILING ADDRESS (IF DIFFERENT FROM THE STREET ADDRESS ABOVE):
_________________________________________________________________________________________________
STREET
APT. #
_________________________________________________________________________________________________
CITY
STATE
ZIP
TELEPHONE NUMBER:

HOME:|__|__|__|-|__|__|__|-|__|__|__|__|

CELL:|__|__|__|-|__|__|__|-|__|__|__|__|

WORK:|__|__|__|-|__|__|__|-|__|__|__|__|

EMAIL ADDRESS: ____________________________________________ @ __________________________________
FACEBOOK NAME: _______________________________________________________________________________
TWITTER HANDLE: _______________________________________________________________________________
OTHER SOCIAL MEDIA CONTACT INFORMATION:___________________________________________________

How would you prefer that we contact you? (Select all that apply)




HOME PHONE
 CELL PHONE
 WORK PHONE
EMAIL
 FACEBOOK
 TWITTER
OTHER – SPECIFY: ___________________________________________________________________________

* This study is sponsored by the National Institutes of Health (NIH), in partnership with the Food and Drug Administration (FDA).

[PATH QR Code]

Do you anticipate moving or relocating either permanently or temporarily in the next 6 to 12 months?


NO



YES – WHERE? __________________________________________________________________

Are you currently attending a college or university?

 NO

 YES

[IF YES] What are the name and location of the college or university?
__________________________________________________________________________________________
Do you have plans to attend a college or university away from this address in the next 6 to 12 months?


NO



YES

[IF YES] What are the name and location of the college or university? ________________________________

Thank you for your time.
Public reporting burden for this collection of information is estimated to average 8 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC
7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-XXXX). Do not return the completed form to this address.