Contact Form

Replication of Recovery and Reunification Interventions for Families-Impact Study (R3-Impact)

Instr.2_Contact Form_clean

Contact Form

OMB: 0970-0616

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Quarterly Contact Information Tracking Communication & Form


[DATE]


«First_name» «Last_name»

«ADDRESS_LINE_1» «ADDRESS_LINE_2»

«CITY», «STATE_CODE» «ZIP»

OR «EMAIL ADDRESS»

OR «MOBILE NUMBER FOR SMS MESSAGING»


Dear «First_name» «Last_name»,


Thank you for agreeing to participate in the Parents Empowering Parents (PEP) Study. We are reaching out to you because in «RA MONTH YEAR» you agreed to participate in the PEP Study. As you may recall, when you agreed to participate, «NAME OF INTERVIEWER AT BASELINE» told you that we would contact you every 3 months to confirm your contact information.


I am from a company called Abt Associates that runs the study. The Administration for Children and Families in the U.S. Department of Health and Human Services is paying for it. By being in the study, you can help build knowledge about what helps parents and could help improve services for families in the future.


Around «Month/Year 15 months after RA», we will invite you to complete a survey to learn about your recent experiences. The survey will take about 45 minutes of your time. In appreciation of your time and effort, you will receive a $40 gift card after you complete the survey.


We want to keep in touch and be able to reach you for the next survey! To help ensure we can reach you for the next survey, please review and update your contact information and the contact information of up to three people who usually know where to reach you. As a reminder, we would call these friends or relatives only if we cannot reach you and ask them if they have any updated contact information. We would not share that you are participating in the study, or anything else about you.


You may have also received an email or a text message asking you to update this information. If you have already done so, you may disregard this letter. Verifying your contact information should take about 5 minutes and you can do it right now in one of three ways:


  1. Fill out the enclosed form. This form presents the information you provided when we spoke last.

    1. If there are no changes, for each question, check the box that says “Yes.”

    2. If your address, email address, or telephone number are different from the information listed, please update as needed.

    3. Please confirm the names, addresses, and telephone numbers of up to three people who usually know where to reach you.

    4. After you complete the form, please return it to us in the enclosed postage paid envelope.


  1. Make any changes online by visiting [Study Website/unique link] or scanning this QR code.

    1. Enter your unique PIN «res_id»

    2. Please visit the website to confirm your information is correct and make any updates needed to your information and the information of three people who usually know where to reach you.


  1. Call the PEP study toll-free line at 888-844-1512

    1. Have your unique PIN «res_id» when you call.

    2. If there are no changes, let us know that your information is correct.

    3. Let us know if there are any updates to your phone number, address or email.


We will send you $5 to thank you for your time and effort once we hear from you.

Being in the Parents Empowering Parents Study is completely up to you, and you can end your participation at any time.


All information you provide will be kept private. The only exception is that we may have to tell someone if we find out that you or someone else could be hurt or in danger—we will try to make sure you or that person get help and are safe. We are required to report concerns of child maltreatment to the study director, and, if needed, to the appropriate agency. Your participation in the study will not affect your child welfare case or the services or public benefits you get.


Thank you, again, for being part of this important study! Please contact us at 888-844-1512 (toll-free call) or by email at [email protected] if you have any questions.


Sincerely yours,


Kim Francis

Study Director

Abt Associates



THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13): This collection of information is voluntary and will be used to understand programs that provide peer mentoring for parents involved in the child welfare system. Public reporting burden of the described voluntary collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, gathering, and maintaining the data needed, 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. The OMB number and expiration date for this collection are OMB #: 0970-0616, Exp: 9/30/2026. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to Kimberly Francis (Abt Associates) 617-520-2502.


«res_id»


1. Is this the correct spelling of your name?

«First_name» «Last_name»

Please check appropriate box. o Yes o No, the correct spelling is:

First Name

Middle Name

Last Name

Suffix (Sr./Jr.)


2. Is this your current address?

«ADDRESS_LINE_1» «ADDRESS_LINE_2» «CITY», «STATE_CODE» «ZIP»

Please check appropriate box. o Yes o No, my current address is:

Street

Apartment #

City

State

Zip Code


  1. Is this your current phone number? «Phone1» «Phone2»

Please check appropriate box. o Yes o No, my correct phone number is:

Main Phone Number (Cell)

Alternate Phone Number (Work/Home)


Area Code



Telephone Number



Area Code



Telephone Number



  1. Is this your current email address? «Email»

Please check appropriate box. o Yes o No, my correct email address is:

Email Address

Alternate Email Address


5. Is <<preferred contact method>> still your preferred contact method?

Please check appropriate box. o Yes o No, I would prefer: ________________


6. When you enrolled in the study, you provided the contact information for three people who will know how to reach you in case we can’t reach you. We would tell them that we are a researcher at Abt Associates, that you provided them as someone who would know how to get in touch with them and ask them if they have any updated contact information. We would not share that you are participating in the study, any details about the services you are receiving, or anything else about you.


Are these still the best people for us to reach out to in case we can’t reach you?


«Contact 1»

Please check appropriate box.

o Yes, and their information is the same.

o No, their information has changed, or please reach out to the following instead:

1. Name

Relation to you

Address


Apartment #

City

City

State


Zip Code

Phone

Email Address




«Contact 2»

Please check appropriate box.

o Yes, and their information is the same.

o No, their information has changed, or please reach out to the following instead:

2. Name

Relation to you

Address


Apartment #

City

City

State


Zip Code

Phone

Email Address




«Contact 3»

Please check appropriate box.

o Yes, and their information is the same.

o No, their information has changed, or please reach out to the following instead:


3. Name

Relation to you

Address


Apartment #

City

City

State


Zip Code

Phone

Email Address





File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleAbt Single-Sided Body Template
AuthorJeff Smith
File Modified0000-00-00
File Created2024-07-26

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