Address Correction Info

BD-STEPS– Protocol #2087

Address Correction Form (English), March 24, 2015

Birth Defects Study To Evaluate Pregnancy exposureS

BD-STEPS Appointment and Contact Information

To participate in the BD-STEPS.

If you would like to set up an appointment for an interview or have questions about the study, you may call us at our toll-free number, 1-888-743-7324. Or you may return this form with your telephone number and the best times to call you (below).

The telephone number and address we have for you [pre populate below]:

<Main Telephone Number>

<Alternate Telephone Number(s)>

<Name>

<Address>

<Apt. or Lot Number>

<City, State, Zip>

Are the address and phone number we have for you correct? If not, please make relevant corrections (please print), and return this form to us in the prepaid envelope, or you can email us at [email protected] .

Main Telephone Number: ______________________________ Check box if cell phone

Alternate Telephone Number(s): ______________________ Check box if cell phone

Name ____________________________________________________________

Address __________________________________________________________

Apt. or Lot Number _________________________________________________

City, State, Zip_____________________________________________________

Day(s), including Saturday & Sunday, and time(s) you can be reached at the above number(s):

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

May we (also) contact you by email?____ Email address:__________________________

If you do not have a phone, please list name and number of another contact person here.

Name of Other Contact Person: _______________________________________

Contact Phone: ________________________________ Check box if cell phone

Relationship: ______________________________________________________

Thank You!