Form 23 Search to Locate Participants

WHI

Form 23 - Search to Locate Participant

Ver. 8.2
OMB # 0925-0414 Exp: 7/13

Comments:

- Affix label hereMember ID: __ __

__ __ - ___ ___ ___ - ___

First Name ________________________M.I.______
Last Name _________________________________
Public reporting burden for this collection of information is estimated to average 5 minutes 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 OMV control number. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance
Office, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0414). Do not return the completed form to this address.

Complete questions 1, 2, and 3 to initiate a search. Complete questions 4, 5 and 6 at conclusion of search.
Complete Question 7 to document all attempts to locate participant.
1.

Background of search
1.1 Date of last contact with the WHI RC: ___ ___ - ___ ___ - ___ ___ (M/D/Y)
1.2 Reasons for starting the search (more than one may apply):
___ WHI Extension Study participant has been identified as “lost to follow-up” (e.g., appears on
WHIX 1591 – Participants Who Are Lost to Follow-up)
___ Incorrect, incomplete, or invalid mailing address
___ Telephone number is incorrect, disconnected, or no longer in service (optional search)
___ Other (Specify): _______________________________

2. Initiation Date:

-

3. Initiated By:

-

-

(M/D/Y)

Data enter questions 4, 5, and 6 at conclusion of search. (Update existing key-entered form; do not start a new
form. Complete Form 9 – Participation Status for a change in participant follow-up status.)

-

-

4.

Date Search Ended:

5.

Search Ended By:

6.

Search Result: (Required at conclusion of Lost-To-Follow-Up search)

1

4

(M/D/Y)

-

The participant has been located.
(If participant was lost-to-follow-up and has been found, complete and key enter Form 9 – Participation
Status with updated follow-up status information.)
(Includes deceased participants. Complete Form 120 – Initial Notification of Death for a participant
identified as deceased.)
The participant could not be located.

Comments: ___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

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WHI

7.

Form 23 - Search to Locate Participant

Ver. 8.2

Record of attempts to locate a participant. Complete and document all relevant tasks associated
with the Vital Status/Lost-to-Follow-Up search. (Use any, all, or other sources as available.) Note:
all tasks may not apply.
Check activities
completed

a)

Check local telephone directory for current telephone number and current address. .......................................

_____

b)

Check with directory assistance for current phone number. ..............................................................................

_____

c)

Make phone calls to participant’s home to verify address................................................................................

_____

d)

Mail a letter to the last known address for the participant, requesting that she contact
the RC ...................................................................................................................................................................

_____

Date_______________
e)

Date_______________

Date_______________

Make phone calls to personal contacts listed on Personal Information Update ...............................................
Date_______________

Date_______________

_____

Date_______________

f)

Contact any other sources listed on Personal Information Update. ...............................................................

_____

g)

Consult reverse directory (Polk or Coles) and contact current resident
and/or neighbors at last known address. .......... ...............................................................................................

_____

Make phone calls to physician/medical contacts. .............................................................................................

_____

h)

Date_______________

Date_______________

Date_______________

i)

Consult Post Office for current address.............. ...............................................................................................

_____

j)

Mail a certified letter (marked “restrictive delivery”) to the last known address for the participant,
requesting that she contact the RC.......................................................................................................................

_____

Date_______________

Date_______________

k)

Check with the Department of Motor Vehicles for current address. ..................................................................

_____

l)

Check with Social Security Administration for vital status. ...............................................................................

_____

m) Conduct Internet search for lost-to-follow-up participant. See Form 23 Instructions for a variety of web sites.

_____

n)

_____

Other (specify): ................................................. ...............................................................................................

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