Contact Information Form

2PM Screener

Qualitative research to understand consumer opinions and preferences for emerging

HIV prevention products among MSM in Atlanta, Houston, and Miami

Attachment 2b: Contact Information Form

STUDY ID (IN HOUSE USE ONLY) :_______

Date: ______________

Recruiter___________

Location____________

2PM Contact Form

Form Approved

OMB No: XXXX-XXX

Exp. Date: MM/DD/YYYY

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 privacy 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 advance understanding of consumer preferences about emerging biomedical products designed to prevent HIV transmission among men who have sex with men.

Public reporting burden of this collection of information is estimated to average 5 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-New)

We appreciate your interest in the study. I will need your name and phone number so we can reach you to schedule your appointment. When you arrive to your appointment, per CDC COVID-guidelines, we request that you wear a mask.

1. What is your preferred name? _________________________________________________

2. Please provide me with a contact number where we can reach you with a reminder.

Phone 1 ____________________

1. Is there another number as well? Phone 2 ____________________

2. Is it okay for me to leave a message if you are not available to answer?

Yes [ ] No [ ]

3. Is it okay to text your cell phone if you are not available to answer?

Yes [ ] No [ ]

4. Is it ok to leave a call back number with someone who answers the phone?

Yes [ ] No [ ]

3. Is there an email address that you would like me to use to contact you?

1. YES Specify ________________________________________________________

2. NO _____________________________________________________________

KEEP CONTACT INFORMATION SECURED.

IT IS PRIVATE INFORMATION.