Registration Form

Attachment 3a

Registration Form -

Contact Confirmation and Scheduling Preference

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/20xx

Assurance of Confidentiality – We take your privacy very seriously. All information that relates to or describes identifiable characteristics of individuals, a practice, or an establishment will be used only for statistical purposes. NCHS staff, contractors and agents will not disclose or release responses in identifiable form without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m(d)) and the Confidential Information Protection and Statistical Efficiency Act of 2002 (CIPSEA, Title 5 of Public Law 107-347). In accordance with CIPSEA every NCHS employee, contractor, and agent has taken an oath and is subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable information about you. In addition, NCHS complies with the Cybersecurity Enhancement Act of 2015. This law requires the Federal government to protect its information by using computer security programs to identify cybersecurity risks against federal computer networks.

NOTICE - CDC estimates the average public reporting burden for this collection of information as 15 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 Information Collection Review Office, 1600 Clifton Road, NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx).

Registration Form – Contact Confirmation and Scheduling Preference

The registration module is designed for respondents to confirm their contact information and to communicate their scheduling preferences online or by telephone. A login ID and a password are provided in the advance packages for the respondent to use with the module.

The respondent will be asked to confirm the following information:

• Name,

• Address, and

• Phone number(s).

In addition, the respondent will be asked to provide the following information to help us schedule the appointment that works best for him/her:

• The best time to reach him/her (choose all that apply)

	Morning (8AM to Noon)	Afternoon (Noon to 5PM)	Evening (5PM to 9PM)
Weekday
Weekend

• Any anticipated absence/unavailability during the next 3 months (for example, vacation, or business trip), and

• Additional information that can help us schedule the appointment.

Once the respondent completes the registration questionnaire, a representative will call and schedule a home visit (for living participant) or a phone interview (for deceased participant proxy) with him/her. The registration questionnaire is attached below.

REGISTRATION – CONTACT CONFIRMATION AND SCHEDULING PREFERENCE

RIQ.600 Thank you for contacting us at the NHANES Longitudinal Study. First, we need you to verify some information.

Are you:

{SP/PROXY NAME}

YES 1 (RIQ.625)

NO 2

CAPI INSTRUCTION:

DISPLAY SP OR PROXY NAME (PREFIX, FIRST NAME, MIDDLE INITIAL, LAST NAME, SUFFIX) BASED ON NAME USED FOR ADVANCE MAILING.

RIQ.605 Are you answering on behalf of {SP/PROXY NAME}?

YES 1

NO 2 (RIQ.710)

RIQ.610 What is your name?

a/b/c/d/e

Drop Down List

Dr.

Mr.

Mrs.

Ms.

Miss

Master

FIRST NAME

If no middle name, enter “NMN”.

MIDDLE NAME

LAST NAME

SUFFIX

CAPI INSTRUCTION:

• ALLOW SUFFIX TO BE LEFT BLANK.

• DISPLAY ALL FIELDS ON A SINGLE SCREEN.

RIQ.615 How old are you?

Less than 18 years 1

18 to 39 years 2

40 to 59 years 3

60 years or older 4

RIQ.620 What is your relationship to {SP/PROXY NAME}?

Spouse (Wife/Husband) or Partner 1

Daughter or Son (Biological/Adoptive/
In-Law/Step/Foster) 2

Parent (Biological/Adoptive/Step/Foster) 3

Grandparent (Grandmother/Grandfather) 4

Brother/Sister 5

Other Relative 6

Non-Relative 7

RIQ.625 {Do you/Does {SP}/Does {PROXY NAME}} currently go by another name besides {SP/PROXY NAME}?

YES 1

NO 2 (RIQ.635)

CAPI INSTRUCTION:

• IF RIQ.605 = 1, AND ADVANCE MAILING SENT TO THE SP (i.e., SP IS PRESUMED ALIVE), DISPLAY “Does {SP}”.

• IF RIQ.605 = 1, AND ADVANCE MAILING SENT TO PROXY (i.e., SP IS PRESUMED DECEASED), DISPLAY “Does {PROXY NAME}”.

• OTHERWISE, DISPLAY “Do you”.

RIQ.630 What is the name {you/SP/PROXY NAME} currently go/goes by?

a/b/c/d/e

Drop Down List

Dr.

Mr.

Mrs.

Ms.

Miss

Master

FIRST NAME

If no middle name, enter “NMN”.

MIDDLE NAME

LAST NAME

SUFFIX

CAPI INSTRUCTION:

• IF RIQ.605 = 1, AND ADVANCE MAILING SENT TO THE SP (i.e., SP IS PRESUMED ALIVE), DISPLAY “{SP}” and “goes”.

• IF RIQ.605 = 1, AND ADVANCE MAILING SENT TO PROXY (i.e., SP IS PRESUMED DECEASED), DISPLAY “{PROXY NAME}” and “goes”.

• OTHERWISE, DISPLAY “you” and “go”.

• ALLOW SUFFIX TO BE LEFT BLANK.

• DISPLAY ALL FIELDS ON A SINGLE SCREEN.

RIQ.635 Is this {your/SP’s/PROXY NAME’s} current mailing address?

{DISPLAY ADDRESS}

YES 1 (RIQ.650)

NO 2

CAPI INSTRUCTION:

• IF RIQ.605 = 1, AND ADVANCE MAILING SENT TO THE SP (i.e., SP IS PRESUMED ALIVE), DISPLAY “SP’s”.

• IF RIQ.605 = 1, AND ADVANCE MAILING SENT TO PROXY (i.e., SP IS PRESUMED DECEASED), DISPLAY “Is {PROXY NAME}’s}.

• OTHERWISE, DISPLAY “your”.

• DISPLAY ADDRESS USED FOR ADVANCE MAILINGS.

RIQ.640 Please make corrections to the mailing address.

a/b/c/d/e/f

______________________ ___________________________ _____________________

a. STREET #/PO BOX #/ b. STREET NAME/ c. APARTMENT NUMBER

RR BOX # RR #

_____________________ |____|____| |___|____|____|____|____|

d. TOWN OR e. 2 LETTER f. POSTAL CODE

CITY NAME STATE ABBREVIATION OR ZIP CODE

CAPI INSTRUCTION:

• DISPLAY ADDRESS FROM RIQ.635 AND ALLOW RESPONDENT TO MAKE UPDATES TO INDIVIDUAL FIELDS.

• DISPLAY ALL FIELDS ON A SINGLE SCREEN.

RIQ.645 You have recorded {your/SP’s/{PROXY NAME}’s} mailing address as:

{DISPLAY ADDRESS}

Is that correct?

YES 1 (RIQ.650)

NO 2 (RIQ.640)

CAPI INSTRUCTION:

• DISPLAY ADDRESS FROM RIQ.640.

• IF RIQ.645 =2, RETURN TO RIQ.640 AND ALLOW RESPONDENT TO MAKE CORRECTIONS.

• IF RIQ.605 = 1, AND ADVANCE MAILING SENT TO THE SP (i.e., SP IS PRESUMED ALIVE), DISPLAY “SP’s”.

• IF RIQ.605 = 1, AND ADVANCE MAILING SENT TO PROXY (i.e., SP IS PRESUMED DECEASED), DISPLAY “Is {PROXY NAME’s}.

• OTHERWISE, DISPLAY “your”.

RIQ.646 Is {your/SP’s/PROXY NAME}’s} street address the same as the mailing address?

YES 1 (RIQ.650)

NO 2

CAPI INSTRUCTION:

• IF RIQ.605 = 1, AND ADVANCE MAILING SENT TO THE SP (i.e., SP IS PRESUMED ALIVE), DISPLAY “SP’s”.

• IF RIQ.605 = 1, AND ADVANCE MAILING SENT TO PROXY (i.e., SP IS PRESUMED DECEASED), DISPLAY “Is {PROXY NAME}’s}.

• OTHERWISE, DISPLAY “your”.

RIQ.647 Is this {your/SP’s/PROXY NAME’s} current street address?

{DISPLAY ADDRESS}

YES 1 (RIQ.650)

NO 2

CAPI INSTRUCTION:

• IF RIQ.605 = 1, AND ADVANCE MAILING SENT TO THE SP (i.e., SP IS PRESUMED ALIVE), DISPLAY “SP’s”.

• IF RIQ.605 = 1, AND ADVANCE MAILING SENT TO PROXY (i.e., SP IS PRESUMED DECEASED), DISPLAY “Is {PROXY NAME’s}”.

• OTHERWISE, DISPLAY “your”.

• DISPLAY STREET ADDRESS.

RIQ.648 Please make corrections to the street address.

a/b/c/d/e/f

______________________ ___________________________ _____________________

a. STREET NUMBER b. STREET NAME c. APARTMENT NUMBER

_____________________ |____|____| |___|____|____|____|____|

d. TOWN OR e. 2 LETTER f. POSTAL CODE

CITY NAME STATE ABBREVIATION OR ZIP CODE

CAPI INSTRUCTION:

• DISPLAY ADDRESS FROM RIQ.647 AND ALLOW RESPONDENT TO MAKE UPDATES TO INDIVIDUAL FIELDS.

• DISPLAY ALL FIELDS ON A SINGLE SCREEN.

RIQ.649 You have recorded {your/SP’s/{PROXY NAME}’s} street address as:

{DISPLAY ADDRESS}

Is that correct?

YES 1 (RIQ.650)

NO 2 (RIQ.648)

CAPI INSTRUCTION:

• DISPLAY ADDRESS FROM RIQ.648.

• IF RIQ.649 =2, RETURN TO RIQ.648 AND ALLOW RESPONDENT TO MAKE CORRECTIONS.

• IF RIQ.605 = 1, AND ADVANCE MAILING SENT TO THE SP (i.e., SP IS PRESUMED ALIVE), DISPLAY “SP’s”.

• IF RIQ.605 = 1, AND ADVANCE MAILING SENT TO PROXY (i.e., SP IS PRESUMED IS DECEASED), DISPLAY “Is {PROXY NAME}’s}”.

• OTHERWISE, DISPLAY “your”.

RIQ.650 What is the best telephone number to reach {you/SP/PROXY NAME}?

|__|__|__|__|__|__|__|__|__|__|

NO TELEPHONE ACCESS 2 (RIQ.680)

HARD EDIT:

PHONE NUMBER MUST BE 10 DIGITS.

CAPI INSTRUCTION:

• IF RIQ.605 = 1, AND ADVANCE MAILING SENT TO THE SP (i.e., SP IS PRESUMED ALIVE), DISPLAY “SP”.

• IF RIQ.605 = 1, AND ADVANCE MAILING SENT TO PROXY (i.e., SP IS PRESUMED DECEASED), DISPLAY “PROXY NAME”.

• OTHERWISE, DISPLAY “you”.

RIQ.655 What type of phone is this?

Home 1 (RIQ.660)

Office 2 (RIQ.660)

Cell 3 (RIQ.660)

Other 4

RIQ.655OS Specify phone type: _______________________________

RIQ.660 Is there another number where {you/{SP}/PROXY NAME} can be reached?

|__|__|__|__|__|__|__|__|__|__|

NO OTHER PHONE NUMBER 2 (RIQ.680)

HARD EDIT:

PHONE NUMBER MUST BE 10 DIGITS.

CAPI INSTRUCTION:

• IF RIQ.605 = 1, AND ADVANCE MAILING SENT TO THE SP (i.e., SP IS PRESUMED ALIVE), DISPLAY “{SP}”.

• IF RIQ.605 = 1, AND ADVANCE MAILING SENT TO PROXY (i.e., SP IS PRESUMED DECEASED), DISPLAY “{PROXY NAME}”.

• OTHERWISE, DISPLAY “you”.

RIQ.665 What type of phone is this?

Home 1 (RIQ.670)

Office 2 (RIQ.670)

Cell 3 (RIQ.670)

Other 4

RIQ.665OS Specify phone type: _______________________________

RIQ.670 Is there another number where {you/{SP}/{PROXY NAME}} can be reached?

|__|__|__|__|__|__|__|__|__|__|

NO OTHER PHONE NUMBER 2 (RIQ.680)

HARD EDIT:

PHONE NUMBER MUST BE 10 DIGITS.

CAPI INSTRUCTION:

• IF RIQ.605 = 1, AND ADVANCE MAILING SENT TO THE SP (i.e., SP IS PRESUMED ALIVE), DISPLAY “{SP}”.

• IF RIQ.605 = 1, AND ADVANCE MAILING SENT TO PROXY (i.e., SP IS PRESUMED DECEASED), DISPLAY “{PROXY NAME}”.

• OTHERWISE, DISPLAY “you”.

RIQ.675 What type of phone is this?

Home 1 (RIQ.680)

Office 2 (RIQ.680)

Cell 3 (RIQ.680)

Other 4

RIQ.675OS Specify phone type: _______________________________

RIQ.680 We would prefer to contact you at a time that is most convenient for you.

a/b/c/d/e/f What is the best time to reach {you/{SP}/{PROXY NAME}? (CHOOSE ALL THAT APPLY.)

	Morning (8AM to Noon)	Afternoon (Noon to 5PM)	Evening (5PM to 9PM)
Weekday
Weekend

CAPI INSTRUCTION:

• IF RIQ.605 = 1, AND ADVANCE MAILING SENT TO THE SP (i.e., SP IS PRESUMED ALIVE), DISPLAY “{SP}”.

• IF RIQ.605 = 1, AND ADVANCE MAILING SENT TO PROXY (i.e., SP IS PRESUMED DECEASED), DISPLAY “{PROXY NAME}”.

• OTHERWISE, DISPLAY “you”.

RIQ.690 Is there any time during the next 3 months that {you/{SP}/{PROXY NAME}} will be unavailable for more than a few days (for example, on vacation, business trip, etc.)?

YES 1

NO 2 (RIQ.700)

CAPI INSTRUCTION:

• IF RIQ.605 = 1, AND ADVANCE MAILING SENT TO THE SP (i.e., SP IS PRESUMED ALIVE), DISPLAY “{SP}”.

• IF RIQ.605 = 1, AND ADVANCE MAILING SENT TO PROXY (i.e., SP IS PRESUMED DECEASED), DISPLAY “{PROXY NAME}”.

• OTHERWISE, DISPLAY “you”.

RIQ.695 Please indicate the dates {you/{SP}/{PROXY NAME} will not be available.

a/b/c/d

From: |___|___|/|___|___| To: |___|___|/|___|___|

M M D D M M D D

CAPI INSTRUCTION:

• IF RIQ.605 = 1, AND ADVANCE MAILING SENT TO THE SP (i.e., SP IS PRESUMED ALIVE), DISPLAY “ {SP}”.

• IF RIQ.605 = 1, AND ADVANCE MAILING SENT TO PROXY (i.e., SP IS PRESUMED DECEASED), DISPLAY “{PROXY NAME}”.

• OTHERWISE, DISPLAY “you”.

RIQ.700 Please provide any other information, including times that will work best for you, in order to schedule the appointment.

____________________________________________________________

CAPI INSTRUCTION:

• ALLOW ITEM TO BE LEFT BLANK.

• IF RIQ.605 = 1, AND ADVANCE MAILING SENT TO THE SP (i.e., SP IS PRESUMED ALIVE), DISPLAY “{SP}”.

• IF RIQ.605 = 1, AND ADVANCE MAILING SENT TO PROXY (i.e., SP IS PRESUMED DECEASED), DISPLAY “{PROXY NAME}”.

• OTHERWISE, DISPLAY “you”.

BOX 1

CHECK ITEM RIQ.705:

GO TO RIQ.720.

RIQ.710 Thank you for contacting us, but our records do not match your login information. Please call the toll free number 1-800-XXX-XXXX for assistance (9 AM to 4:30 PM, ET).

BOX 2

CHECK ITEM RIQ.715:

GO TO END.

RIQ.720 Thank you for answering these questions. A NHANES Health Representative will call {you/SP/{PROXY NAME} within the next 2 weeks to schedule a {home visit/phone interview}.

CAPI INSTRUCTION:

• IF RIQ.605 = 1, AND ADVANCE MAILING SENT TO THE SP (i.e., SP IS PRESUMED ALIVE), DISPLAY “{SP}” and “home visit”.

• IF RIQ.605 = 1, AND ADVANCE MAILING SENT TO PROXY (i.e., SP IS DECEASED), DISPLAY “{PROXY NAME}” and “phone interview”.

• OTHERWISE, DISPLAY “you” and “home visit”.