Previously Approved Tracking Letter and Contact Update form

Supporting Statement for OMB Clearance Request

Appendix O: HPOG-Impact and HPOG-NIE Tracking Letter and Contact Update Form

National Implementation Evaluation of the Health Profession Opportunity Grants (HPOG) to Serve TANF Recipients and Other Low-Income Individuals and HPOG Impact Study

0970-0394

April 24, 2013

Submitted by:

Office of Planning,
Research & Evaluation

Administration for Children & Families

U.S. Department of Health
and Human Services

Federal Project Officers:

Molly Irwin and Mary Mueggenborg

Appendix O: HPOG-Impact and HPOG-NIE Tracking Letter and Contact Update Form

OMB Control No. 0970-0394 OMB approval expires xx/xx/xxxx Abt Associates IRB Approval No. 0572 Urban Institute IRB Approval No. 08592-100/110-00

[FIRST] [LAST]

[ADDRESS]

[ADDRESS 2]

[CITY], [ZIP] [STATE]

[DATE]

Dear [FIRST],

I am writing to ask you to confirm or update your address information for a research project on the Health Profession Opportunity Grants Program (HPOG) being conducted by Abt Associates and its subcontractors for the Administration for Children and Families (ACF), U.S. Department of Health and Human Services (DHHS).

Recently, you applied to receive services through the Health Profession Opportunity Grants Program (HPOG) in your community or region. At that time, you agreed to participate in research that will help ACF evaluate the HPOG program. Thank you for agreeing to be part of this important study.

When you agreed to be in the study, you gave consent to participate in a follow-up survey for which you will receive $30 in appreciation for your time. However, if you move during the next few months, we might not be able to reach you. We want to make sure that we have your correct email and/or street address so we can contact you next year for the follow-up survey. To make sure that our records are accurate, please verify your contact information in one of the following ways:

1) You may call in any changes to: [insert SRBI 800#]. Please clearly state your unique PIN [userid] and any updates to your phone number, address, or email. If there are no changes to your contact information please say, “no changes” and the PIN [userid].

2) You may fill out the enclosed form with any updates to your phone number, address, or email and return it in the postage paid envelope. If there are no changes to the information provided, please simply check the box at the top of the form and return it in the postage paid envelope.

This information will help us greatly when we attempt to contact you and will only be used for that purpose. Your continuing participation in this study is very important and greatly appreciated. Feel free to contact us if you have any questions about the HPOG study at toll-free 1-8xx-xxx-xxxx or [email protected]. Thank you for your time.

Sincerely,

Alan Werner, Ph.D. Robin Koralek

Project Director of the HPOG Impact Study Project Director of the HPOG National Implementation Evaluation

On the left side of this form, you will find the last contact information we have for you. Please update any new information on the right side. Check the box if there have been no changes. Please send this form back in the postage paid envelope provided.

Check here if there are no changes to the following information 

PRESENT INFORMATION

[Pfullnm]

Participant’s Name

MAILING ADDRESS:

[sStreet]

Street

[sCity]

City

[sState ]

[sZip]

State Zip

[sHLP]

Participant’s Landline Phone

[sCell]

Participant’s Cell Phone

[Pfullnm]

Name of person #1 who will know how to contact you

[Pfullnm]

Name of person #2 who will know how to contact you

[Pfullnm]

Name of person #3 who will know how to contact you

[sCell]

Cell of person #1 who will know how to contact you

[sCell]

Cell of person #2 who will know how to contact you

[sCell]

Cell of person #2 who will know how to contact you

UPDATED INFORMATION

Participant’s Name

MAILING ADDRESS:

Street

City

State Zip

-

-

Participant’s Landline Phone

-

-

Participant’s Cell Phone

Name of person #1 who will know how to contact you

Name of person #2 who will know how to contact you

Name of person #3 who will know how to contact you

-

-

Cell of person #1 who will know how to contact you

-

-

Cell of person #1 who will know how to contact you

-

-

Cell of person #1 who will know how to contact you

Please update your email address below if it is no longer: [sEmail]

Participant’s Email Address

Please update email address below if it is no longer: [sEmail]

Email Address of person #1 who will know how to contact you

Please update email address below if it is no longer: [sEmail]

Email Address of person #1 who will know how to contact you

Please update email address below if it is no longer: [sEmail]

Email Address of person #1 who will know how to contact you

Thank you! Please place this form in the pre-addressed, postage-paid envelope that you received and drop it in any U.S. Postal Service mailbox.

________________________________________________________________

According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13), no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information collection is 0970-0394. The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. This information collection is voluntary. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer.