Appendix H Contact Update Letter and Form

Supporting Statement for OMB Clearance Request

Appendix H: Contact Update Letter and 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

August November, 2014

Submitted by:

Office of Planning,
Research & Evaluation

Administration for Children & Families

U.S. Department of Health
and Human Services

Federal Project Officers:

Hilary Forster and Mary Mueggenborg

Appendix H: Contact Update Letter and Form

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

<address>

January 27, 2021

Dear <first name>,

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.

Recently, you applied to receive services through HPOG in your community or region: <HPOG name>. 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 $40 in appreciation for your time. However, if you move during the next few months, we might not be able to reach you. We will contact you every 3-4 months until it is time to participate in the survey in order to update your contact information. 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; we are enclosing $2 to thank you for doing so:

1) You may email any changes to: [email protected]. On the subject line please indicate your unique PIN <rid>. If there are no changes to your contact information please write, “no changes” and the PIN <rid> in the subject line.

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 that says “this is correct” 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 1-855-551-0919 or [email protected]. Thank you for your time.

Sincerely,

[PROJECT DIRECTOR SIGNATURE]

PROJECT DIRECTOR NAME

Project Director of the HPOG Impact Study

Participant Records Verification

Please verify that the information we have on file for you is accurate.

Return this form in the included envelope (postage paid).

Personal Information Verification

We have your NAME as: «First_Name» «Middle_Initial» «Last_Name»  This is correct  This is not correct (print correct information below)

Enter updated NAME: Full Name:

Last

First

M.I.

We have your ADDRESS as: «Street» «Apt» «City» «State» «Zip» - «Zip5»  This is correct  This is not correct (print correct information below)

Enter Updated Address:

Street Address

Apartment/Unit #

City

State

ZIP Code

We have your MAILING ADDRESS as: «Street» «Apt» «City» «State» «Zip» - «Zip5»

Enter Updated Address:

Last

First

M.I.

Street Address

Apartment/Unit #

City

State

ZIP Code

We have your primary PHONE NUMBER as: «Primary_Phone».  This is the best number to reach me  This is not the best number to reach me (print correct information below)

Enter best PHONE NUMBER: Primary Phone:

( )

Alternate Phone:

( )

 cell  home  work other  cell  home  work other

Secondary Contacts: Person 1

Please check below and correct the names, addresses and telephone numbers of the three people you previously provided us who are living outside your household and usually know where to reach you. The name, address, phone #s and relationship to you of best person who will always know where to reach you is: Name : Address: Primary phone number:  This is the best person to reach me  This is NOT the best person to reach me (print correct information below) Enter Updated contact information name, address, relationship and phone numbers.

Full Name:

First & Last

Relationship

Address:

Street Address & Apartment/Unit # City State

ZIP Code

Primary Phone:

( )

Alternate Phone:

( )

 cell  home  work other  cell  home  work other

Secondary Contacts: Person 2
Name : Address: Primary phone number:  SECOND person contact information is correct  SECOND person contact information is NOT correct (print correct information below) Enter Updated person 2 name, address, relationship and phone numbers.
Full Name:
	First & Last			Relationship
Address:
	Street Address & Apartment/Unit # City State					ZIP Code
Primary Phone:		( )	Alternate Phone:		( )

 cell  home  work other  cell  home  work other

Secondary Contacts: Person 3
Name : Address: Primary phone number:  THIRD person contact information is correct  THIRD person contact information is NOT correct (print correct information below) Enter Updated person 3 name, address, relationship and phone numbers.
Full Name:
	First & Last			Relationship
Address:
	Street Address & Apartment/Unit # City State					ZIP Code
Primary Phone:		( )	Alternate Phone:		( )

 cell  home  work other  cell  home  work other