Sample Contact Information Form

Form Approved

OMB No. 0920-XXXX

Exp. Date XX/XX/XXXX

Attachment 3b Sample Contact Information Form

Using Rapid Assessment Methods to Understand Issues in

HIV Prevention, Care and Treatment in the United States

Public reporting burden of this collection of information is estimated to average 1 minute 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 CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-New)

Contact Information

During conversation assess their ability to speak English or Spanish (should be able to converse without difficulty). If you determine English AND Spanish very poor—not eligible.

If they sound bizarre on the phone (disorganized thoughts, confrontational, angry, etc.)—not eligible.

Participant Contact Information

IF STUDY COHORT FILLED OR YOU DETERMINE THEY ARE NOT ELIGIBLE:

“We appreciate your interest in the study. I’m going to forward this information to the recruiting coordinator to determine if you are eligible for this study. If you are eligible, we will get back to you with more details. I’ll need your first name and phone number so we can reach you if you qualify. Thank you for your interest in participating in our study.

If study cohort is not filled and you determine that they ARE eligible:

It looks like you qualify for the study. I need to get your contact information so an interviewer can call and arrange the exact time and location to interview you.

What is your name?

Please provide me with two contact numbers where I can reach you as a reminder.

1. Is it okay for me to leave a message if you are not available to answer?”

Yes [ ] No [ ]

2. Is it okay to text your cell phone if you are not available to answer?”

Yes [ ] No [ ]

KEEP CONTACT INFORMATION LOCKED. IT IS PRIVATE INFORMATION. IT SHOULD NOT BE KEPT IN ELECTRONIC FORMAT.