Appendix H Contact Letter and Form_Updated August 2015

Attachment 1: Currently Approved Contact Update Form, OMB Control No. 0970-0394

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:

 _{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:

 _{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:

 This is where I want my $5 check sent

 _{This is not where I want my $5 check sent (print correct information below)}

Enter Updated Address:

In care of:

^Last _First ^M.I.

Street Address Apartment/Unit #

_City ^{State ZIP Code}

We have your primary PHONE NUMBER as:

 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

Do we have your permission to contact you via text message to your cell phone? Please answer yes or no for permission to send a regular text and to send an automated text. (An automated text message is a prewritten message that is sent at a later date such as a text that reminds you to complete a form or call to set up an appointment.)

 Yes, you may contact me via text message  Yes, you may contact me via automated text message

to my cell phone. to my cell phone.

 _{No, you may not contact me via text message}  _{No, you may not contact me via automated text message to my cell phone. o your cell phone}

We have your primary EMAIL Address as:

 This is the best email to reach me

 _{This is not the best email to reach me (print correct information below)}

_{Enter best EMAIL Address: @:}

_{PLEASE SEE ADDITIONAL INFORMATION ON BACK SIDE}

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 : Relationship:

Address:

Primary phone number: Alternative phone number is:

 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:

Address:

First & Last Relationship

_{Street Address & Apartment/Unit # City State ZIP Code}

Primary Phone: _{( )} Alternate Phone: _{( )}

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

_{Email: @:}

Secondary Contacts: Person 2

Name : Relationship:

Address:

Primary phone number: Alternative phone number is:

 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:

Address:

First & Last Relationship

_{Street Address & Apartment/Unit # City State ZIP Code}

Primary Phone: _{( )} Alternate Phone: _{( )}

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

_{Email: @:}

Secondary Contacts: Person 3

Name : Relationship:

Address:

Primary phone number: Alternative phone number is:

 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.}

Address:

First & Last Relationship

_{Street Address & Apartment/Unit # City State ZIP Code}

Primary Phone: _{( )} Alternate Phone: _{( )}

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

Email: @:

Attachment 2: HPOG Impact Draft Online Contact Update Form

[HPOG Logo]

Dear [FNAME] [LNAME],

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

In [RA MONTH/YEAR], 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 $30 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 phone number, street address and/or email so we can contact you in the future for the follow-up survey. To make sure that our records are accurate, please verify your contact information by filling out the following online form with any updates to your phone number, address, or email. We will send you a $5 check to thank you for completing the form.

This information will help us greatly when we attempt to contact you to complete the follow-up survey 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,

Gretchen Locke

Project Director of the HPOG Impact Study

OMB Control No. 0970-0394
OMB approval expires 12/31/2017

Abt Associates IRB Approval No. 0572
Urban Institute IRB Approval No. 08592-100/110-00

[PAGE END]

[SECTION TITLE:] NAME VERIFICATION

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

[PAGE END]

Q1 We have your NAME as: [FNAME] [MNAME] [LNAME]

1. This is correct SKIP TO Q5

2. This is not correct CONTINUE

[PAGE END]

[SECTION TITLE:] NAME UPDATE

Please update your name.

Q2 First name: [text box]

Q3 Middle initial: [text box]

Q4 Last name: [text box]

[PAGE END]

[SECTION TITLE:] ADDRESS RECORDS VERIFICATION

Q5 We have your ADDRESS as

			This is correct	This is not correct
A	Street Address 1	[ADDRESS1]	1	2
B	Apartment/Unit	[ADDRESS2]	1	2
C	City	[CITY]	1	2
D	State	[STATE]	1	2
E	Zip	[ZIP]	1	2

[PAGE END]

[SECTION TITLE:] ADDRESS UPDATE

Please update your address.

Q6 Address: [text box]

Q7 Apartment/Unit: [text box]

Q8 City: [text box]

Q9 State: [drop down of 50 states + D.C.]

Q10 ZIP Code: [text box; validate as ZIP]

[PAGE END]

[SECTION TITLE:] MAILING ADDRESS VERIFICATION

Q11 We have your MAILING ADDRESS as:

			This is correct	This is not correct
A	Street Address 1	[ADDRESS1]	1	2
B	Apartment/Unit	[ADDRESS2]	1	2
C	City	[CITY]	1	2
D	State	[STATE]	1	2
E	Zip	[ZIP]	1	2

[PAGE END]

[SECTION TITLE:] MAILING ADDRESS UPDATE

Q12 Address: [text box]

Q13 Apt: [text box]

Q14 City: [text box, fill from Q8]

Q15 State: [drop down of 50 states + D.C,]

Q16 ZIP Code: [text box, fill from Q10, validate as ZIP]

[PAGE END]

[SECTION TITLE:] PRIMARY PHONE VERIFICATION

Q17 We have your primary phone number as: [HPHONE].

1. This is the best number to reach me SKIP TO Q23

2. This is not the best number to reach me CONTINUE

[PAGE END]

[SECTION TITLE:] PHONE NUMBER UPDATES

Please update your phone number.

Q18 Please enter your primary phone: ([NNN]) [NNN]-[NNNN]

Q19 What type of phone number is this?

1. Cell

2. Home

3. Work

4. Other

Q19b. Do we have your permission to contact you via text message to your cell phone? Please answer yes or no for permission to send a regular text and to send an automated text. (An automated text message is a prewritten message that is sent at a later date such as a text that reminds you to complete a form or call to set up an appointment.)

1a. Yes, you may contact me via text message.to my cell phone.

2a. No, you may not contact me via text message to my cell phone.

1b. Yes, you may contact me via automated text message to my cell phone

2b. No, you may not contact me via automated text message to my cell phone.

IF CPHONE IS MISSING SKIP TO Q21

IF CPHONE IS NOT MISSING CONTINUE

[PAGE END]

[SECTION TITLE:] ALTERNATE PHONE VERIFICATION

Q20 We have your alternative phone number as: [CPHONE].

1. This is the best alternative number to reach me SKIP TO Q22

2. This is not the best alternative number to reach me CONTINUE

[PAGE END]

[SECTION TITLE:] PHONE NUMBER UPDATES

[IF CPHONE IS MISSING: Please provide an alternative phone number to {IF Q17=1 HPHONE / IF Q17=2: Q18}, if you have one / IF CPHONE IS NOT MISSING: Please update your alternative phone number].

Q21 Please enter your alternative phone: ([NNN]) [NNN]-[NNNN]

Q22 What type of phone number is this?

1. Cell

2. Home

3. Work

4. Other

[SECTION TITLE:] EMAIL VERIFICATION

Q23 We have your primary EMAIL as: [EMAIL]

1. This is the best email to reach me SKIP TO Q25

2. This is not the best email to reach me CONTINUE

[PAGE END]

[SECTION TITLE:] EMAIL UPDATE

Q24 Enter best EMAIL Address: [text box, validate string as email]

[PAGE END]

[SECTION TITLE:] SECONDARY CONTACTS: PERSON 1

In previous contacts, you gave us the names, addresses and contact information for the following people. 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.

Q25 Is [CONTACT1_FNAME] [CONTACT1_LNAME] still a person who does not live with you and will always know how to contact you?

1. Yes CONTINUE

2. No SKIP TO Q27

[PAGE END]

[SECTION TITLE:] SECONDARY CONTACTS: PERSON 1

Q26 Please confirm that the information in our records for [CONTACT1_FNAME] [CONTACT1_LNAME] is correct:

			This is correct	This is not correct
A	Street Address 1	[CONTACT1_ADDRESS1]	1	2
B	Apartment/Unit	[CONTACT1_ADDRESS2]	1	2
C	City	[CONTACT1_CITY]	1	2
D	State	[CONTACT1_STATE]	1	2
E	Zip	[CONTACT1_ZIP]	1	2
F	Primary Phone	[CONTACT1_PHONE]	1	2
G	Alternate Phone	[CONTACT2_PHONE2]	1	2
H	Email	[CONTACT1_EMAIL]	1	2
I	Relationship	[CONTACT1_RELATIONSHIP]	1	2

[PAGE END]

[SECTION TITLE:] SECONDARY CONTACTS: PERSON 1

Please enter the name of someone who does not live with you and will always know how to contact you.

Q27 First name: [text box]

Q28 Last name: [text box]

[PAGE END]

[SECTION TITLE:] SECONDARY CONTACTS: PERSON 1

Q29 What is [IF Q25=1: CONTACT1_FNAME / IF Q25=2: Q27] [IF Q25=1: CONTACT1_LNAME / IF Q25=2: Q27]’s relationship to you?

1. Parent

2. Friend/social support network

3. Extended biological family member

4. Sibling

5. Partner/spouse

6. Other (please specify: [TEXT BOX])

[PAGE END]

[SECTION TITLE:] SECONDARY CONTACTS: PERSON 1

Please [IF Q25=1: update / IF Q25≠1: enter] the address of [IF Q25=1: CONTACT1_FNAME / IF Q25=2: Q27] [IF Q25=1: CONTACT1_LNAME / IF Q25=2: Q28].

Q30 Address: [text box]

Q31 Apartment/Unit: [text box]

Q32 City [text box]

Q33 State: [drop down of 50 states + D.C]

Q34 ZIP Code: [text box; validate zip]

[PAGE END]

[SECTION TITLE:] SECONDARY CONTACTS: PERSON 1

Please [IF Q25=1: update / IF Q25≠1: enter] the [IF Q25=1|(Q26F≠1&Q26G≠1): telephone numbers / IF Q26F=1|Q26G=1: telephone number] of [IF Q25=1: CONTACT1_FNAME / IF Q25=2: Q27] [IF Q25=1: CONTACT1_LNAME / IF Q25=2: Q28].

Q35 Primary phone: ([NNN]) [NNN]-[NNNN]

Q36 Alternate phone: ([NNN]) [NNN]-[NNNN]

[PAGE END]

[SECTION TITLE:] SECONDARY CONTACTS: PERSON 1

Please [IF Q25=1: update / IF Q53≠1: enter] the email address of [IF Q25=1: CONTACT1_FNAME / IF Q25=2: Q27] [IF Q25=1: CONTACT1_LNAME / IF Q25=2: Q28].

Q37: Email: [text box; validate as email address]

[PAGE END]

[SECTION TITLE:] SECONDARY CONTACTS: PERSON 2

Q38 Is [CONTACT2_FNAME] [CONTACT2_LNAME] still a person who does not live with you and will always know how to contact you?

1. Yes CONTINUE

2. No SKIP TO Q40

[PAGE END]

[SECTION TITLE:] SECONDARY CONTACTS: PERSON 2

Q39 Please confirm that the information in our records for [CONTACT2_FNAME] [CONTACT2_LNAME] is correct:

			This is correct	This is not correct
A	Street Address 1	[CONTACT2_ADDRESS1]	1	2
B	Apartment/Unit	[CONTACT2_ADDRESS2]	1	2
C	City	[CONTACT2_CITY]	1	2
D	State	[CONTACT2_STATE]	1	2
E	Zip	[CONTACT2_ZIP]	1	2
F	Primary Phone	[CONTACT2_PHONE]	1	2
G	Alternate Phone	[CONTACT2_PHONE2]	1	2
H	Email	[CONTACT2_EMAIL]	1	2
I	Relationship	[CONTACT2_RELATIONSHIP]	1	2

[PAGE END]

[SECTION TITLE:] SECONDARY CONTACTS: PERSON 2

Please enter the name of someone who does not live with you and will always know how to contact you.

Q40 First name: [text box]

Q41 Last name: [text box]

[PAGE END]

[SECTION TITLE:] SECONDARY CONTACTS: PERSON 2

Q42 What is [IF Q38=1: CONTACT2_FNAME / IF Q38=2: Q40] [IF Q38=1: CONTACT2_LNAME / IF Q38=2: Q41]’s relationship to you?

1. Parent

2. Friend/social support network

3. Extended biological family member

4. Sibling

5. Partner/spouse

6. Other (please specify: [TEXT BOX])

[PAGE END]

[SECTION TITLE:] SECONDARY CONTACTS: PERSON 2

Please [IF Q38=1: update / IF Q38≠1: enter] the address of [IF Q38=1: CONTACT2_FNAME / IF Q38=2: Q40] [IF Q38=1: CONTACT2_LNAME / IF Q38=2: Q41].

Q43 Address: [text box]

Q44 Apartment/Unit: [text box]

Q45 City [text box]

Q46 State: [drop down of 50 states + D.C]

Q47 ZIP Code: [text box; validate zip]

[PAGE END]

[SECTION TITLE:] SECONDARY CONTACTS: PERSON 2

Please [IF Q38=1: update / IF Q38≠1: enter] the [IF Q38=1|(Q39F≠1&Q39G≠1): telephone numbers / IF Q39F=1|Q39G=1: telephone number] of [IF Q38=1: CONTACT2_FNAME / IF Q38=2: Q40] [IF Q38=1: CONTACT2_LNAME / IF Q38=2: Q41].

Q48 Primary phone: ([NNN]) [NNN]-[NNNN]

Q49 Alternate phone: ([NNN]) [NNN]-[NNNN]

[PAGE END]

[SECTION TITLE:] SECONDARY CONTACTS: PERSON 2

Please [IF Q38=1: update / IF Q38≠1: enter] the email address of [IF Q38=1: CONTACT2_FNAME / IF Q38=2: Q40] [IF Q38=1: CONTACT2_LNAME / IF Q38=2: Q41].

Q50: Email: [text box; validate as email address]

[PAGE END]

[SECTION TITLE:] SECONDARY CONTACTS: PERSON 3

Q51 Is [CONTACT3_FNAME] [CONTACT3_LNAME] still a person who does not live with you and will always know how to contact you?

1. Yes CONTINUE

2. No SKIP TO Q53

[PAGE END]

[SECTION TITLE:] SECONDARY CONTACTS: PERSON 3

Q52 Please confirm that the information in our records for [CONTACT3_FNAME] [CONTACT3_LNAME] is correct:

			This is correct	This is not correct
A	Street Address 1	[CONTACT3_ADDRESS1]	1	2
B	Apartment/Unit	[CONTACT3_ADDRESS2]	1	2
C	City	[CONTACT3_CITY]	1	2
D	State	[CONTACT3_STATE]	1	2
E	Zip	[CONTACT3_ZIP]	1	2
F	Primary Phone	[CONTACT3_PHONE]	1	2
G	Alternate Phone	[CONTACT3_PHONE2]	1	2
H	Email	[CONTACT3_EMAIL]	1	2
I	Relationship	[CONTACT3_RELATIONSHIP]	1	2

[PAGE END]

[SECTION TITLE:] SECONDARY CONTACTS: PERSON 3

Please enter the name of someone who does not live with you and will always know how to contact you.

Q53 First name: [text box]

Q54 Last name: [text box]

[PAGE END]

[SECTION TITLE:] SECONDARY CONTACTS: PERSON 3

Q55 What is [IF Q51=1: CONTACT3_FNAME / IF Q51=2: Q53] [IF Q51=1: CONTACT3_LNAME / IF Q51=2: Q54]’s relationship to you?

1. Parent

2. Friend/social support network

3. Extended biological family member

4. Sibling

5. Partner/spouse

6. Other (please specify: [TEXT BOX])

[PAGE END]

[SECTION TITLE:] SECONDARY CONTACTS: PERSON 3

Please [IF Q51=1: update / IF Q51≠1: enter] the address of [IF Q51=1: CONTACT3_FNAME / IF Q51=2: Q53] [IF Q51=1: CONTACT3_LNAME / IF Q51=2: Q54].

Q56 Address: [text box]

Q57 Apartment/Unit: [text box]

Q58 City: [text box]

Q59 State: [drop down of 50 states + D.C]

Q60 ZIP Code: [text box; validate zip]

[PAGE END]

[SECTION TITLE:] SECONDARY CONTACTS: PERSON 3

Please [IF Q51=1: update / IF Q51≠1: enter] the [IF Q51=1|(Q52F≠1&Q52G≠1): telephone numbers / IF Q52F=1|Q52G=1: telephone number] of [IF Q51=1: CONTACT3_FNAME / IF Q51=2: Q53] [IF Q51=1: CONTACT3_LNAME / IF Q51=2: Q54].

Q61 Primary phone: ([NNN]) [NNN]-[NNNN]

Q62 Alternate phone: ([NNN]) [NNN]-[NNNN]

[PAGE END]

[SECTION TITLE:] SECONDARY CONTACTS: PERSON 3

Please [IF Q51=1: update / IF Q51≠1: enter] the email address of [IF Q51=1: CONTACT3_FNAME / IF Q51=2: Q53] [IF Q51=1: CONTACT3_LNAME / IF Q51=2: Q54].

Q61: Email: [text box; validate as email address]

[PAGE END]

END Thank you! Your answers have been submitted.

Month: «type»

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