Appendix F_Previously Approved Contact Info. Update Form

PACE Followup OMB Appendix F_Previously Approved Contact Info. Update Form.docx

Pathways for Advancing Careers and Education (PACE) – Third Follow-up Data Collection

Appendix F_Previously Approved Contact Info. Update Form

OMB: 0970-0397

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Supporting Statement for OMB Clearance Request


Appendix F: Previously Approved Contact Update Form



Pathways for Advancing Careers and Education (PACE) – Follow-up Data Collection


OMB No. 0970-0397





March 2017




Submitted by:

Nicole Constance

Office of Planning, Research
and Evaluation

Administration for Children
and Families

U.S. Department of Health and Human Services





Participant Contact Update Form

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: «First_Name» «Middle_Initial» «Last_Name»

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: «Street» «Apt» «City» «State» «Zip» - «Zip5»

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: «Street» «Apt» «City» «State» «Zip» - «Zip5»





Enter Updated Address:
















Last

First

M.I.










Street Address

Apartment/Unit #










City

State

ZIP Code









We have your primary PHONE NUMBER as: «Primary_Phone».

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 to my cell phone message to your cell phone




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 :

Address:

Primary phone number:

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:





First & Last

Relationship


Address:




Street Address & Apartment/Unit # City State

ZIP Code

Primary Phone:

( )

Alternate Phone:

( )


cell home work other cell home work other



Secondary Contacts: Person 2


Name :

Address:

Primary phone number:

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:





First & Last

Relationship


Address:




Street Address & Apartment/Unit # City State

ZIP Code

Primary Phone:

( )

Alternate Phone:

( )


cell home work other cell home work other

Secondary Contacts: Person 3


Name :

Address:

Primary phone number:

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.


Full Name:





First & Last

Relationship


Address:




Street Address & Apartment/Unit # City State

ZIP Code

Primary Phone:

( )

Alternate Phone:

( )


cell home work other cell home work other





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