Locator section for adults (C.2)

Attachment C.2

Locator Section for Adults

RIViR Study

RIViR Study

Locator Section for Adults (will be inserted after the first instrument administered)

Name
Would it be okay if RTI contacts you for another interview after this part of the study is over? You could decide at that time whether you want to participate.	Yes/No

If YES:
What is your preferred phone number that we may call? Please enter phone number in the 999-999-9999 format.	__________________________________  Prefer not to provide a phone number
May we text you at this number?	Yes/No
Do you have a secondary phone number that we may call? Please enter phone number in the 999-999-9999 format.	__________________________________  Prefer not to provide a phone number
May we text you at this number?	Yes/No
What is an address that we may mail information to (if it’s okay with you)?	Street: City: Zip: State:  Prefer not to answer
What is an e-mail address that we may send information to (if it’s okay with you)?	__________________________________  Prefer not to answer

Can we contact someone else in the case that we cannot reach you?	Yes/No
If YES: What is the name of that contact? What is the telephone number for that contact? Please enter phone number in the 999-999-9999 format.	__________________________________  Prefer not to answer __________________________________  Prefer not to provide a phone number

The Paperwork Reduction Act Statement: Public reporting burden for this collection of information is estimated to average 10 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: RTI International, 3040 E Cornwallis Rd, Durham NC, 27709 ATTN: Tasseli McKay (919-485-5747). Do not return the completed form to this address.

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