Locator

“Exploring HIV Prevention Communication Among Black Men Who Have Sex with Men in New York City: Project BROTHA”

Attachment 5b/ Locator Form

BMSM

BMSM: Locator Information

Today’s Date : __ __ / __ __ / __ __ __ __ ID Number: ____ ____ ____ ____

Last name __________________________ First name __________________ MI ___

Street Address _____________________________________________ Apt # ______

City _______________________ State ________________ Zip ________

Day # ( )________________ Evening # ( )_________________

Cell/Pager ( )______________ Email ______________________

Best time to call _______________

Preferred way to identify project (circle one):

• City University of New York/CUNY

• CHEST

• GMAD

• Other ________

Discretion when contacting? YES NO

Messages OK? YES NO

CONTACT PERSON (someone with whom there is regular contact in the case that the current address and phone numbers are no longer valid)

Last name __________________________ First name __________________ MI ___

Relationship to person ____________________________________________________

Street Address _____________________________________________ Apt # ______

City _______________________ State ________________ Zip ________

Day # ( )________________ Evening # ( )_________________

Cell/Pager ( )______________ Email ______________________