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pdfPublic reporting burden for this collection of information is estimated to average 05
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 (0925-0584). Do not return the completed form to this address.
OMB#: 0925-0584
Exp. xx/xx/xxxx
HCHS/SOL Personal Identifiers
FORM CODE: IDE
VERSION: 1, 12/12/13
ID NUMBER:
Contact
Occasion
0
2
SEQ #
ADMINISTRATIVE INFORMATION
0a. Completion Date:
/
Month
0b. Staff ID:
/
Day
Year
Instructions: Complete this form for each eligible participant. All responses are important to complete fully,
including the contacts. Use location codes at end for coding address.
I am going to ask you for your full name, address, and phone number. Please remember that all
information that you give us is confidential, and only certified HCHS/SOL personnel will have access to
this information.
A. Identifying Information
1 a. Title: _____________ b. First Name: _______________________
c. Middle/Second Name: ____________________________________
d. Paternal Last Name: _____________________________________
e. Maternal Last Name: ____________________________________
f. Extension/Suffix: ________________________________________
As part of the confidential information we collect on the participants in HCHS/SOL we ask for your Social
Security Number. Please review the disclosure statement as I read it to you. The statement explains the
reasons why we are requesting your Social Security Number and that providing it is voluntary.
Disclosure Statement: We are asking for your Social Security Number because data from
this study will be linked with data supplied by health care providers for approved research
purposes only. It will be kept confidential according to the Privacy Act of 1974 and will be
used only for research purposes. Providing this information to the Hispanic Community
Health Study / Study of Latinos is entirely voluntary on your part, but it is extremely
important for the purposes of this study.
(Interviewer: After reading the Disclosure Statement, ask participant if he/she has any questions.)
2 Do you have a social security number?
No
0
Yes
1
Don’t know/Not sure
2
Go to Question 3
Refused
9
Go to Question 3
Personal Identifiers Form (PIE)
Go to Question 3
Page 1 of 10
FORM CODE: IDE
VERSION: 1, 12/12/2013
ID NUMBER:
Contact
Occasion
0
2
SEQ #
a. If yes, ask the participant if they are willing to provide the number:
3
-
Do you have a driver’s license issued in a U.S. state or Puerto Rico?
No
0
Yes
1
Don’t know/Not sure
2
Go to Question 4
Refused
9
Go to Question 4
Go to Question 4
a. If yes, ask the participant if they are willing to provide the number:
B. Participant Address/Telephone
It is very important for this study to be able to reach you. Please provide us with your current home
address. We will not give your address information to anyone else.
4
Current home address*
4.A.1. PO Box, Box &/or Route and Number
4.B.1. Street Number Prefix
4.B.2. Street Number
4.B.3. Street Number Suffix
4.C.1. Street Name Prefix
4.C.2. Street Name
4.C.3. Street Name Type
4.C.4. Street Name Suffix
4.D.1. Unit Type
4.D.2. Unit Type Identifier
4.D.3. Unit Subtype
IDE-Personal Identifiers-12-12-13.docx
Page 2 of 10
FORM CODE: IDE
VERSION: 1, 12/12/2013
ID NUMBER:
Contact
Occasion
0
2
SEQ #
4.D.4. Unit Subtype Identifier
4.E.1. Other
4.F.1. City
4.G.1. County
4.H.1. State
4.I.1. Country/Territory (Select code from list)
4.J.1. Zip Code
5
–
About how long have you lived at this address? Since…
5.A.1. Year
5.A.2. Month
IF UNKNOWN, ENTER 99
5.A.3. Day
IF UNKNOWN, ENTER 99
*IF THE PARTICIPANT LIVES AT SEVERAL LOCATIONS, ENTER WHERE HE OR SHE LIVES MOST. IF
THE EXACT ADDRESS IS UNKNOWN, ENTER THE NAME OF THE INTERSECTION OR STREET CLOSEST
TO THE HOME LOCATION IN 4.C.2. AND THE NAME OF THE BUILDING OR LOCATION IN 4.E.1.
IF THE ONLY KNOWN HOME ADDRESS IS A POST OFFICE BOX, BOX, OR ROUTE AND NUMBER,
ENTER IT IN 4.A.1., BUT ALSO ENTER THE NAME OF THE INTERSECTION OR STREET CLOSEST TO
THE ACTUAL HOME LOCATION IN 4.C.2. AND THE NAME OF THE BUILDING OR LOCATION IN 4.E.1.
6
(
Primary Phone Number: +
(Country Code)
6a: This is a: Cell Phone
1
)
Home Phone 2
7
What is the best time of day to reach you at this number?
Morning
1
Afternoon
2
Evening
3
8
Secondary Phone Number: +
(
(Country Code)
IDE-Personal Identifiers-12-12-13.docx
-
(Area Code)
)
-
(Area Code)
Page 3 of 10
FORM CODE: IDE
VERSION: 1, 12/12/2013
ID NUMBER:
8a: This is a: Cell Phone
9
1
Contact
Occasion
0
2
SEQ #
Home Phone 2
What is the best time of day to reach you at this number?
Morning
1
Afternoon
2
Evening
3
10 Email address 1:
10a. Email address 2:
11 How do you prefer to receive information from us? (select only one)
Regular Mail
1
Electronic mail (email)
2
Social Media (Facebook and Twitter)
4
In Person at time of clinic visit
5
Text messages
6
Other
7
Specify: ______________________
C. Local Contact 1
12 a. Title: _______________ b. First Name: ____________________
c. Second Name: _________________________________________
d. Last Name: ___________________________________________
e. Maternal Last Name: ______________________________________
13 Relationship: ______________________
10a. is this ARE contact?
No
0
Yes
1
14 Current home address of primary contact*
14.A.1. PO Box, Box &/or Route and Number
14.B.1. Street Number Prefix
14.B.2. Street Number
14.B.3. Street Number Suffix
IDE-Personal Identifiers-12-12-13.docx
Page 4 of 10
FORM CODE: IDE
VERSION: 1, 12/12/2013
ID NUMBER:
Contact
Occasion
0
2
SEQ #
14.C.1. Street Name Prefix
14.C.2. Street Name
14.C.3. Street Name Type
14.C.4. Street Name Suffix
14.D.1. Unit Type
14.D.2. Unit Type Identifier
14.D.3. Unit Subtype
14.D.4. Unit Subtype Identifier
14.E.1. Other
14.F.1. City
14.G.1. County
14.H.1. State
14.I.1. Country/Territory (Select code from list)
14.J.1. Zip Code
–
*IF THE PERSON LIVES AT SEVERAL LOCATIONS, ENTER WHERE HE OR SHE LIVES MOST. IF THE
EXACT ADDRESS IS UNKNOWN, ENTER THE NAME OF THE INTERSECTION OR STREET CLOSEST TO
THE HOME LOCATION IN 14.C.2. AND THE NAME OF THE BUILDING OR LOCATION IN 14.E.1.
IF THE ONLY KNOWN HOME ADDRESS IS A POST OFFICE BOX, BOX, OR ROUTE AND NUMBER,
ENTER IT IN 14.A.1., BUT ALSO ENTER THE NAME OF THE INTERSECTION OR STREET CLOSEST TO
THE ACTUAL HOME LOCATION IN 14.C.2. AND THE NAME OF THE BUILDING OR LOCATION IN 14.E.1.
(
15 Telephone: +
)
(Country Code)
15a: This is a: Cell Phone
(Area Code)
1
number
Home Phone 2
16 Email address 1:
IDE-Personal Identifiers-12-12-13.docx
Page 5 of 10
FORM CODE: IDE
VERSION: 1, 12/12/2013
ID NUMBER:
Contact
Occasion
0
2
SEQ #
16a. Email address 2:
D. Local Contact 2
17 a. Title: _______________ b. First Name: ____________________
c. Middle/Second Name: ___________________________________
d. Paternal Last Name: ____________________________________
e. Maternal Last Name: ______________________________________
18 Relationship: __________________
18a. is this ARE contact?
No
0
Yes
1
19 Current home address of secondary contact*
19.A.1. PO Box, Box &/or Route and Number
19.B.1. Street Number Prefix
19.B.2. Street Number
19.B.3. Street Number Suffix
19.C.1. Street Name Prefix
19.C.2. Street Name
19.C.3. Street Name Type
19.C.4. Street Name Suffix
19.D.1. Unit Type
19.D.2. Unit Type Identifier
19.D.3. Unit Subtype
19.D.4. Unit Subtype Identifier
IDE-Personal Identifiers-12-12-13.docx
Page 6 of 10
FORM CODE: IDE
VERSION: 1, 12/12/2013
ID NUMBER:
Contact
Occasion
0
2
SEQ #
19.E.1. Other
19.F.1. City
19.G.1. County
19.H.1. State
19.I.1. Country/Territory (Select code from list)
19.J.1. Zip Code
–
(
20 Telephone: +
)
(Country Code)
20.a: This is a: Cell Phone
(Area Code)`
1
number
Home Phone 2
21 Email address 1:
21.a. Email address 2:
*IF THE PERSON LIVES AT SEVERAL LOCATIONS, ENTER WHERE HE OR SHE LIVES MOST. IF THE
EXACT ADDRESS IS UNKNOWN, ENTER THE NAME OF THE INTERSECTION OR STREET CLOSEST TO
THE HOME LOCATION IN 19.C.2. AND THE NAME OF THE BUILDING OR LOCATION IN 19.E.1.
IF THE ONLY KNOWN HOME ADDRESS IS A POST OFFICE BOX, BOX, OR ROUTE AND NUMBER,
ENTER IT IN 19.A.1., BUT ALSO ENTER THE NAME OF THE INTERSECTION OR STREET CLOSEST TO
THE ACTUAL HOME LOCATION IN 19.C.2. AND THE NAME OF THE BUILDING OR LOCATION IN 19.E.1.
E. Local Contact 3
22 a. Title: _______________ b. First Name: ____________________
c. Middle/Second Name: ___________________________________
d. Paternal Last Name: ____________________________________
e. Maternal Last Name: ______________________________________
23 Relationship: __________________
21 a. is this ARE contact?
No
0
Yes
1
24 Current home address of third contact*
IDE-Personal Identifiers-12-12-13.docx
Page 7 of 10
ID NUMBER:
FORM CODE: IDE
VERSION: 1, 12/12/2013
Contact
Occasion
0
2
SEQ #
24.A.1. PO Box, Box &/or Route and Number
24.B.1. Street Number Prefix
24.B.2. Street Number
24.B.3. Street Number Suffix
24.C.1. Street Name Prefix
24.C.2. Street Name
24.C.3. Street Name Type
24.C.4. Street Name Suffix
24.D.1. Unit Type
24.D.2. Unit Type Identifier
24.D.3. Unit Subtype
24.D.4. Unit Subtype Identifier
24.E.1. Other
24.F.1. City
24.G.1. County
24.H.1. State
24.I.1. Country/Territory (Select code from list)
24.J.1. Zip Code
IDE-Personal Identifiers-12-12-13.docx
–
Page 8 of 10
FORM CODE: IDE
VERSION: 1, 12/12/2013
ID NUMBER:
(
25 Telephone: +
)
(Country Code)
25.a: This is a: Cell Phone
Contact
Occasion
0
2
SEQ #
-
(Area Code)
1
Home Phone 2
26 Email address 1:
26.a. Email address 2:
*IF THE PERSON LIVES AT SEVERAL LOCATIONS, ENTER WHERE HE OR SHE LIVES MOST. IF THE
EXACT ADDRESS IS UNKNOWN, ENTER THE NAME OF THE INTERSECTION OR STREET CLOSEST TO
THE HOME LOCATION IN 24.C.2. AND THE NAME OF THE BUILDING OR LOCATION IN 24.E.1.
IF THE ONLY KNOWN HOME ADDRESS IS A POST OFFICE BOX, BOX, OR ROUTE AND NUMBER,
ENTER IT IN 24.A.1., BUT ALSO ENTER THE NAME OF THE INTERSECTION OR STREET CLOSEST TO
THE ACTUAL HOME LOCATION IN 24.C.2. AND THE NAME OF THE BUILDING OR LOCATION IN 24.E.1.
IDE-Personal Identifiers-12-12-13.docx
Page 9 of 10
FORM CODE: IDE
VERSION: 1, 12/12/2013
ID NUMBER:
Contact
Occasion
0
2
SEQ #
Location Codes for Question 4.I.1, 14.I.1, 19.I.1, and 24.I.1
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
Afghanistan
Anguilla
Antigua and Barbuda
Argentina
Aruba
Australia
Austria
Bangladesh
Belgium
Belize
Bolivia
Brazil
Canada
Chile
China
Colombia
Costa Rica
Cuba
Czech Republic
Denmark
Dominican Republic
Ecuador
El Salvador
Finland
France
Germany
Great Britain
Greece
Guam
Guatemala
Haiti
Holland
Honduras
Hungary
IDE-Personal Identifiers-12-12-13.docx
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
99
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Japan
Korea
Lebanon
Malaya
Mexico
New Zealand
Nicaragua
Norway
Pakistan
Panama
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Russia
South Africa
Spain
Sweden
Switzerland
United States
Uruguay
Venezuela
Virgin Islands
Other
Unknown/refused
Page 10 of 10
| File Type | application/pdf |
| File Modified | 2014-05-30 |
| File Created | 2014-05-30 |