Form 0920-22FZ Att 4h_Provider Locator Form

[NCHHSTP] mChoice: Improving PrEP Uptake and Adherence among Minority MSM through Tailored Provider Training and Adherence Assistance in Two High Priority Settings

Att 4h_Provider Locator Form

Provider Locator Form

OMB: 0920-1428

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Form Approved

OMB No. 0920-New

Expiration Date: XX/XX/XXXX








mChoice: Improving PrEP Uptake and Adherence among Minority MSM through Provider Training and Adherence Assistance in Two High Priority Settings


Attachment 4h

Provider Locator Form
























Public reporting burden of this collection of information is estimated to average 10 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)



Locator Form

Date form completed or updated:_________________(mm/dd/yyyy)



Fill out as much tracking information as possible. You may withhold certain pieces of data that you choose not to share.


Information collected on this form will be used to contact you when it is time to complete a study visit (i.e. meeting with your practice coach, clinic assessment tool or follow-up interview). The information that you provide will be kept in a separate place from the answers to any questions that you have provided. It will only be used to locate you during the study period and will not be given to anyone else. If we reach out through a phone call, and you are not the one who picks up the phone, we will not share any information about your participation in the study. We will simply identify ourselves and provide you with a callback number. May we have the following information and your permission to use the information to try to contact you?



Participant Information

Participant’s full legal name:

First:______________________________

Middle: ______________________________

Last: ______________________________

Nickname/Preferred Name: ______________________________

Preferred Pronoun: ______________________________

Clinic:

  • Birmingham AIDS Outreach

  • University of Alabama at Birmingham 1917 Clinic

  • Callen-Lorde Community Health Center

  • Columbia University Nurse Practitioner Primary Care Group



Participant’s home address:

Number and street: ______________________________

City or town: ______________________________ State: ____________ Zip Code: ____________

Can we send you information at this address? ______ No ______ Yes



Participant’s contact information:

Primary phone number (xxx-xxx-xxxx): ________________________

Type:

  • Home phone

  • Cell phone

  • Message phone

If you are not available, is it okay to leave a message at this number regarding the research project?

__ No __ Yes

If yes, what can the message say?_____________________________________________________



Secondary phone number (xxx-xxx-xxxx):______________

Type:

  • Home phone

  • Cell phone

  • Message phone

If you are not available, is it okay to leave a message at this number regarding the research project?

__ No __ Yes

If yes, what can the message say?_____________________________________________________



Other phone number (xxx-xxx-xxxx):______________

Type:

  • Home phone

  • Cell phone

  • Message phone

If you are not available, is it okay to leave a message at this number regarding the research project?

__ No __ Yes

If yes, what can the message say?_____________________________________________________



Can we send you a text message to a cell phone to remind you about your study visits?

__ No __ Yes __ N/A (no access to a cell phone)

If "Yes", cell phone number (xxx-xxx-xxxx):______________



Primary email address:

Type:

  • Personal email

  • Work email

  • Friend/family member email

Can we email you to remind you of study visits? __ No __ Yes __ N/A



Secondary email address:

Type:

  • Personal email

  • Work email

  • Friend/family member email

Can we email you to remind you of study visits? __ No __ Yes __ N/A



Other email address:

Type:

  • Personal email

  • Work email

  • Friend/family member email

Can we email you to remind you of study visits? __ No __ Yes __ N/A







File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorBrin, Maeve
File Modified0000-00-00
File Created2023-11-21

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