Contact Information Form

Form Approved

OMB No: 0920-XXXX

Exp. Date: xx/xx/xxxx

Development of a Mobile Messaging Intervention for Men who have Sex with Men:

4b. Contact Information Form

Congratulations. Based on your answers, you qualify to enroll in our study. Please provide the following information (first name, phone number, email address and contact preference) so we may contact you to schedule your participation in the study. The information you provide here will be kept separate from other information you provide to us in the course of this study, and access to any contact information you provide will be limited to key study staff.

1. What is your first name, nickname, or name you’d like us to call you by?

Name: _______________________________

[using form validation, if provided name has 0 characters, reject entry and prompt user correction with: “You must provide a name to participate in our study”]

2. What is the current, 10-digit phone number for the phone or device you plan to use during this study?

Phone number: (__ __ __) -- __ __ __ -- __ __ __ __

[using form validation, if provided phone number does not have 10 digits, reject entry and prompt user correction with: “You must provide a valid, 10-digit phone number to participate in our study”]

3. What is your current email address?

Email: __________________________________

[using form validation, if provided email address does not conform to ___@___.___ format, reject entry and prompt user correction with: “You must provide a valid email address to participate in our study”]

4. If study staff contacts you regarding participation in the study, how would most prefer to be contacted?

☐ Phone call ☐ Text message ☐ Email ☐ No preference

Please take a moment to review your answers before submitting them. Please make sure that your contact information is accurate, as inaccurate contact information may prevent us from being able to contact you.

If study staff contacts you regarding participation in the study, they will first attempt to contact you by the contact method you prefer. If unable to make contact by the preferred method, study staff will attempt to make contact by other means.

Public reporting burden of this collection of information is estimated to average 1 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: OMB-PRA (0920-XXXX)