Revised Form

FRT2 Adult Participant Information Form REVISED 121313.doc

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

Revised Form

OMB: 0925-0664

Document [doc]
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OMB Control Number: 0925-0664

Expiration Date: 11/30/2015



Adult 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. Filling out this form and returning it using the enclosed postage-paid envelope; OR

  2. Completing the form online by logging into www.pathstudyinfo.nih.gov. (If you have a smartphone, you can scan the QR code below to visit the website.)


As a thank you for completing this form, you’ll receive an additional $5 on your PATH Study debit card (up to $10 a year). (Please contact us toll-free at 1-888-311-1819, if the card was misplaced.)


If none of your contact information has changed, simply check this box:

YOUR NEW CONTACT INFORMATION. PLEASE PRINT CLEARLY.

NAME:

FIRST MI LAST


STREET ADDRESS:

STREET APT. #


CITY STATE/PROVINCE ZIP


COUNTRY


YOUR NEW MAILING ADDRESS (IF DIFFERENT FROM THE STREET ADDRESS ABOVE):


STREET ADDRESS:

STREET APT. #


CITY STATE/PROVINCE ZIP


COUNTRY


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



YOUR NEW TELEPHONE NUMBER(S):

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

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



YOUR NEW PREFERRED EMAIL ADDRESS:

_____________________________________________________@


In addition to mail, how would you prefer that we contact you? (Select all that apply)


HOME PHONE

CELL PHONE (VOICE) CELL PHONE (TEXTING)

PREFERRED EMAIL



NEW CONTACT INFORMATION FOR SOMEONE WHO WILL ALWAYS KNOW HOW TO LOCATE YOU. PLEASE PRINT CLEARLY.

NAME:

FIRST MI LAST


TELEPHONE NUMBER(S):

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

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



PREFERRED EMAIL ADDRESS:

_____________________________________________________@



STREET ADDRESS:

STREET APT. #


CITY STATE/PROVINCE ZIP


COUNTRY




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


NO YES


IF YES, WHEN WILL YOU MOVE?


IF YES, PLEASE PROVIDE YOUR NEW CONTACT INFORMATION


STREET ADDRESS:

STREET APT. #


CITY STATE/PROVINCE ZIP


COUNTRY


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 (0925-0664). Do not return the completed form to this address.

Group 8

FRT2_V0

File Typeapplication/msword
AuthorJuliette Bowrin
Last Modified ByPerryman
File Modified2013-12-18
File Created2013-12-18

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