Locator Form (SUNY)

HIV/AIDS Risk Reduction Interventions for African-American

Heterosexual Men

0920-10CM

Attachment 3d

Data Collection: Locator Form – SUNY

Form Approved

OMB No. 0920-XXXX

Exp. Date XX/XX/20XX

HIV/AIDS Risk Reduction Interventions for African-American

Heterosexual Men: Locator Form – SUNY (Attachment 3d)

Public reporting burden of this collection of information is estimated to average 5 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 persons 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 (0920-09XX)

Locator Form

I am now going to ask you some information that will help us schedule your follow-up visit, if you are eligible. This information will be destroyed after the study is completed, and will not be used for any other purpose than to contact you for follow-up.

1. Interviewer Initials: ____ ____ ____

2. Date form completed: ____ / ____ / ____

3. Date form updated: ____ / ____ / ____

4. Participant’s Name: _______________________ _________________________ _____

(Last) (First) (MI)

5. Other Names Used:

_______________________________________________________________

6. Participant’s DOB: ____ / ____ / ____

M D Y

7. Address:__________________________________________________________

__________________________________________________________________

8. OK to call participant? If yes, complete information below.

___No (skip to 9)

___Yes

Telephone Numbers: (Home) ______________________________

(Work) ______________________________

(Pager/Beeper) ________________________

(Other, Specify) ______________________________

Best days/times to call: ________________________________________________________________

9. Does respondent have a computer, or access to a computer?

________________________________

10. OK to email participant? If yes, complete information below

___No

___Yes (Respondent’s email: ___________________________________________)

11. How often does respondent check the e-mail account?

______________________________________

12. OK to send mailings? If yes, complete mailing address if different from item #7

_____________________________________________________________________

13. Special Instructions: How would participant like research staff to address themselves when making contact?:

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

14. We will call you to remind you of your appointments, and also send a written note with directions and other important information for your appointment. This note can either be sent by phone or by email. Which of these would be the best way to contact you?

____Phone

____Email

Additional Contact #1:

Name: ___________________________________ Relationship: ______________________

Address: ____________________________________________________

____________________________________________________

Telephone: (work) ___________________________

(home) ___________________________

Language Spoken: ________________________________________________

Special Instructions:______________________________________________________________

------------------------------------------------------------------------------------------------------------

Additional Contact #2:

Name: ___________________________________ Relationship: ______________________

Address: ____________________________________________________

____________________________________________________

Telephone: (work) _____________________________ (home)___________________________

Language Spoken: ________________________________________________

Special Instructions:_____________________________________________________________