Form 2f Followup Tracking Participant/Field Test

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

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

PID (Mini-Label)

OMB Control Number: 0925-XXXX
Expiration Date:

ADULT 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, you’ll receive an additional $5 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 [ADULT’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: _____________________________________
* This study is sponsored by the National Institutes of Health (NIH), in partnership with the Food and Drug Administration (FDA).

[PATH QR Code]

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

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

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

NO



YES – WHERE? ____________________________________________________
Thank you for your time.

Public reporting burden for this collection of information is estimated to average 6 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.