Contact information

Attachment D - Participant Contact Information

Form Approved

OMB No. 0920-0572
Exp. Date 3/31/2018

CDC Air Quality Information Project

Participant Contact Information Sheet

Participant Information

NAME: ________________________________________________________

EMAIL ________________________________________________________

What is the best time to reach you? What is the best telephone number to reach you at that time?

BEST TIME TO BE REACHED: ________________________________________

BEST PHONE NUMBER: ______________

Is there another time and number we can try if we miss you?

ALTERNATE PHONE NUMBER:

Recruiter: ____________________

• Group A (Asthma):

• Group B (COPD):

• Group C (Heart Failure):