TLC Contact Information

Evaluation of TransLife Center (TLC): A Locally-Developed Combination Prevention Intervention for Transgender Women at High Risk of HIV Infection

Att 4b_TLC Contact Information_23Aug2018

Contact Information

OMB: 0920-1246

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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:_______




5


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorBessler, Patricia (CDC/OID/NCHHSTP)
File Modified0000-00-00
File Created2021-01-20

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