Attachment G. Contact Update Letter and Form

Attachment G: Participant Contact Information Update Letter and Form

OMB Control No. XXXX-XXXX OMB approval expires X/XX/201X Abt Associates IRB Approval No. XXXX Urban Institute IRB Approval No. XXX-XX

Ref: [rid]

[address]

[date]

Dear [name],

I am writing to ask you to confirm or update your address information for a research project on the Health Profession Opportunity Grants Program (HPOG) being conducted by [XXX] for the Administration for Children and Families (ACF), U.S. Department of Health and Human Services.

Recently, you applied to receive services through HPOG in your community or region: [name of HPOG program]. At that time, you agreed to participate in research that will help ACF evaluate the HPOG program. Thank you for agreeing to be part of this important study.

When you agreed to be in the study, you gave consent to participate in a follow-up survey for which you will receive $XX in appreciation for your time. However, if you move during the next few months, we might not be able to reach you. We will contact you every 3-4 months until it is time to participate in the survey in order to update your contact information. We want to make sure that we have your correct email and/or street address so we can contact you next year for the follow-up survey. To make sure that our records are accurate, please verify your contact information by filling out the enclosed form with any updates to your phone number, address, or email and return it in the postage paid envelope. If there are no changes to the information provided, please simply check the box at the top of the form and return it in the postage paid envelope. We are enclosing $2 to thank you for returning the form.

This information will help us greatly when we attempt to contact you and will only be used for that purpose. Your continuing participation in this study is very important and greatly appreciated. Feel free to contact [XXX] if you have any questions about the HPOG study at [XXX-XXX-XXXX]. Thank you for your time.

Sincerely,

[Signature]

Project Director of the HPOG Next Gen Impact Study

According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13), no persons are required to respond to a collection of information unless such

collection displays a valid OMB control number. The valid OMB control number for this information collection is xxxx-xxxx. This information collection is voluntary. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer.

Participant Records Verification

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:

 _{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:

 _{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:

 This is where I want my $5 check sent

 _{This is not where I want my $5 check sent (print correct information below)}

Enter Updated Address:

In care of:

^Last _First ^M.I.

Street Address Apartment/Unit #

_City ^{State ZIP Code}

We have your primary PHONE NUMBER as:

 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? This could be regular text or automated text.

 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 message to my cell phone to your cell phone}

We have your primary EMAIL Address as:

 This is the best email to reach me

 _{This is not the best email to reach me (print correct information below)}

_{Enter best EMAIL Address: @:}

We have your FACEBOOK ACCOUNT as:

 _{This is correct}  _{This is not correct (print correct information below)}

Enter Updated Facebook account:

We have your Twitter handle as:

 _{This is correct}  _{This is not correct (print correct information below)}

Enter Updated Twitter hand:

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 : Relationship:

Address:

Primary phone number: Alternative phone number is:

 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:

Address:

First & Last Relationship

_{Street Address & Apartment/Unit # City State ZIP Code}

Primary Phone: _{( )} Alternate Phone: _{( )}

 cell  home  work other  cell  home  work other

_{Email: @:}

Secondary Contacts: Person 2

Name : Relationship:

Address:

Primary phone number: Alternative phone number is:

 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:

Address:

First & Last Relationship

_{Street Address & Apartment/Unit # City State ZIP Code}

Primary Phone: _{( )} Alternate Phone: _{( )}

 cell  home  work other  cell  home  work other

_{Email: @:}

Secondary Contacts: Person 3

Name : Relationship:

Address:

Primary phone number: Alternative phone number is:

 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.}

Address:

First & Last Relationship

_{Street Address & Apartment/Unit # City State ZIP Code}

Primary Phone: _{( )} Alternate Phone: _{( )}

 cell  home  work other  cell  home  work other

Email: @:

Attachment G: Participant Contact Information Update Letter and Form ▌pg. 2