Contact Information Form

Form Approved

OMB Control No. 0920-1140

Exp. Date: 10 / 31 / 2017

Attachment G. Contact information form

Date: _______________

Participant initials: ____________

Interviewer initials: ____________

Recruitment site: __Home __Clinic

First Name: ____________

Paternal Surname: ____________

Maternal surname: ____________

Cell phone number: ____________

Cell phone company: ____________

Alternative phone number: ____________

Email: ____________

Alternative email: ____________

Address: ________________________________________________________________________

Municipality: ____________

Zip code: ____________

Preferred contact method: ____________

Other Contact method: ____________

Secondary contact first name: ____________

Paternal last name: ____________

Maternal last name: ____________

Phone number: ____________

Relationship: ____________

Public reporting burden of this collection of information is estimated to average 2 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 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: PRA 0920-1140