Resident Intake Form

Appendix C: Resident Intake Study Correspondence and Intake Form

The Department of Housing and Urban Development (HUD) is working on renovating properties in your area. It is important to keep track of how residents feel about the renovations as these improvements take place. We hope you will agree to take part in an important study to learn about residents’ feelings and experiences. The study will take place after the improvements are completed in the housing community you live in.

In order for you to be enrolled in the study, we need to be able to contact you several times over the next year or two. So, we are asking you to fill out this form with different types of contact information where we can reach you. We will send you a $5 gift card as a thank-you for signing up to be part of this important study.

The contact information you give us will be kept completely confidential and will be used only to contact you for the study. The information will not in any way affect your eligibility for HUD housing.

If you agree to give us contact information so we can get in touch with you later for the survey, please print and sign your name and fill in the date below.

I agree to provide contact information so I can be reached later for Study XXX.

Print full name: _____________________________________________________

Signature: _____________________________________________________

Today’s date: _____________________________________________________

Contact Information

For any questions that require checking a box, please make an X or other dark mark in the box next to the answer you want to choose.

1. We know people move around a lot. If you plan to move in the next month and know your new address, please write it on the lines below.

Street: _____________________________________________

City: _____________________________________________

State: _____________________________________________

Zip Code: _____________________________________________

 Not planning to move in the next month

2. Please enter your landline (home) phone number in the boxes below. This would be a home number that is not a cell phone.

 Do not have a landline phone number

3. Please enter your cell phone number in the boxes below.

 Do not have a cell phone

4. Are there any other numbers where we can reach you such as a work number or a pager? If so please write them in the boxes below and say what type of number it is (work, pager, etc.)

___________________

Type of number

___________________

Type of number

5. Do we have your permission to send a text message to your cell phone in order to get in touch with you?

• Yes

• No

• Do not have a cell phone/Can’t get texts

6. Please provide your email address as well as an alternate email address where we can reach you if you have one.

Email: ________________________________________

Alternate email: ________________________________________

 Do not have an email address

Additional Contacts

It would be helpful if you could give us a few additional people we could contact if we can’t reach you when it is time to do the survey. If you have relatives or friends who usually know how to reach you, please fill in their contact information below as well as their relationship to you.

Person One

7. Please provide this person’s full name, address and relationship to you.

First and Last Name: _______________________________________

Street Address: _______________________________________

City/State/Zip Code: _______________________________________

Relationship to You: _______________________________________

8. Please enter this person’s landline (home) phone number in the boxes below:

 Does not have a landline phone number

9. Please enter this person’s cell phone number

 Does not have a cell phone

10. Please provide this person’s email address as well as an alternate email address where we can reach this person (if they have one).

Email: _____________________________________________

Alternate email: _____________________________________________

 Does not have an email address

Person Two

11. Please provide this person’s full name, address and relationship to you.

First and Last Name: _______________________________________

Street Address : ______________________________________

City/State/Zip Code: _______________________________________

Relationship to You: _______________________________________

12. Please enter this person’s landline (home) phone number in the boxes below:

 Does not have a landline phone number

13. Please enter this person’s cell phone number

 Does not have a cell phone

14. Please provide this person’s email address as well as an alternate email address where we can reach this person (if they have one).

Email: _____________________________________________

Alternate email: _____________________________________________

 Does not have an email address

Thank you so much for completing this form. Please send it back as soon as possible in the enclosed postage-paid envelope in order to receive your $5.00 thank-you gift card and participate in this important study. We will be in touch with you soon.

Page 4 – Appendix A: Evaluation of RAD - Phase I