Contact Information Form

Attachment 2c: SSP Contact Form

Form Approved

OMB No: 0920-1091

Exp. Date: 09/30/2021

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 evaluate Syringe Service Programs’ (SSP) User Experiences.

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 (0920-1091)

STUDY ID NUMBER (IN HOUSE USE ONLY) :_______

Date: ______________

Recruiter___________

Location____________

SSP Contact Form

Version 1.0

SECTION 1: TO BE COMPLETED AT TIME OF SCREENING:

We appreciate your interest in the study. I’ll need your name and phone number so we can reach you to schedule your interview and/or to remind you of your scheduled interview. As noted during the screening, we will not use your name or contact information when identifying your answers to our questions.

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

4. What city/area are you calling from? ______________________________

5. If known –An interviewer will be in your area the week of [DATE]. If you are eligible, would you be available then for an interview?

Yes

No

KEEP CONTACT INFORMATION SECURED.

IT IS PRIVATE INFORMATION.

SECTION 2: PHONE SCHEDULING - ONCE RESPONDENT IS DETERMINED TO BE ELIGIBLE

Thank you again for your interest in our study. I am calling back about the research study we are conducting in order to better understand the service needs of clients of syringe service programs (SSPs). You have been selected to participate in the study, if you would still like to.

Points to cover:

• The interview takes about one full hour.

• The interview needs to be in person. We’ll have an interviewer in

  • [AREA] at

  • [LOCATION] on

  • [DATES]

• You will receive $40 cash/gift card following the interview.

• Your participation is completely voluntary and you do not have to answer any questions you do not feel comfortable answering.

• Participation in this research will in no way impact any care or services you may be receiving or are entitled to receive.

Do you have any questions?