TLC Contact Information

Form Approved

OMB No. 0920 – New

Expiration Date: XX/XX/XXXX

Evaluation of TransLife Center (TLC): A Locally-Developed Combination Prevention

Intervention for Transgender Women at High Risk of HIV Infection

Attachment 4b

TLC Contact Information

Privacy Act Statement:

This information is collected under the authority of the Public Health Service Act, Section 301, "Research and Investigation," (42 U.S.C. 241); and Sections 304, 306 and 308(d) which discuss authority to maintain data and provide assurances of confidentiality for health research and related activities (42 U.S.C. 242 b, k, and m(d)).  This information is also being collected in conjunction with the provisions of the Government Paperwork Elimination Act and the Paperwork Reduction Act (PRA). This information will only be used by the Centers for Disease Control and Prevention (CDC) staff to evaluate TransLife Center (TLC) as an HIV prevention intervention for transgender women.

Public reporting burden of this collection of information is estimated to average 4 minute 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-New)

Your Information

Preferred First Name: Preferred Last Name: Name used on medical records: Other name/Nickname: Preferred Pronoun:	________________________ ________________________ ____________________________, ____________________________ (Last name) (First name) ________________________ (Optional) ________________________ (she/her, he/him, they, ze, none, other)
Address:
City:		State:	Zip Code:
	Ok to send mail? YES / NO Preferred name (if different from above):_____________________________ Preferred pronoun (if different from above): she/her, he/him, they, ze, none, other:_______
Phone:
	Ok to leave voicemail? YES / NO Preferred name (if different from above):_____________________________ Preferred pronoun (if different from above): she/her, he/him, they, ze, none, other:_______
Alternate phone:
	Ok to leave voicemail? YES / NO Preferred name (if different from above):_____________________________ Preferred pronoun (if different from above): she/her, he/him, they, ze, none, other:_______
Email:
	Ok to mention the program name? YES / NO Preferred name (if different from above):_____________________________ Preferred pronoun (if different from above): she/her, he/him, they, ze, none, other:_______
Alternate email:
	Ok to mention the program name? YES / NO Preferred name (if different from above):_____________________________ Preferred pronoun (if different from above): she/her, he/him, they, ze, none, other:_______
Facebook:
	Ok to mention the program name? YES / NO Preferred name (if different from above):_____________________________ Preferred pronoun (if different from above): she/her, he/him, they, ze, none, other:_______

When we contact you to remind you about an appointment which contact do you prefer?

□ Phone □ Alternate Phone □ Email

□ Alternate Email □ Facebook

Additional Contact #1

Name:
Relationship:
Address: (Street address, City, State, zip)
Phone:
	Ok to leave voicemail? YES / NO Preferred name (if different from above):_____________________________ Preferred pronoun (if different from above): she/her, he/him, they, ze, none, other:_______
Email:
	Ok to mention the program? YES / NO Preferred name (if different from above):_____________________________ Preferred pronoun (if different from above): she/her, he/him, they, ze, none, other:_______

Additional Contact #2

Name:
Relationship:
Address: (Street address, City, State, zip)
Phone:
	Ok to leave voicemail? YES / NO Preferred name (if different from above):_____________________________ Preferred pronoun (if different from above): she/her, he/him, they, ze, none, other:_______
Email:
	Ok to mention the program? YES / NO Preferred name (if different from above):_____________________________ Preferred pronoun (if different from above): she/her, he/him, they, ze, none, other:_______

Additional Contact #3

Name:
Relationship:
Address: Address: (Street address, City, State, zip)
Phone:
	Ok to leave voicemail? YES / NO Preferred name (if different from above):_____________________________ Preferred pronoun (if different from above): she/her, he/him, they, ze, none, other:_______
Email:
	Ok to mention the program? YES / NO Preferred name (if different from above):_____________________________ Preferred pronoun (if different from above): she/her, he/him, they, ze, none, other:_______

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