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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 4b
Patient Locator Form English
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 follow-up study visit (i.e. 3-month, 6-month, 9-month, 12-month or 18-month follow-up visit or an in-depth 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: ______________________________
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
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Brin, Maeve |
| File Modified | 0000-00-00 |
| File Created | 2024-08-05 |