HIV/AIDS Risk Reduction Interventions for African-American
Heterosexual Men
0920-10CM
Attachment 3f
Data Collection: Locator Form – UNCG
Form Approved
OMB No. 0920-XXXX
Exp. Date XX/XX/20XX
HIV/AIDS Risk Reduction Interventions for African-American
Heterosexual Men: Locator Form – UNCG (Attachment 3f)
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)
We want to keep in touch with you!
We are going to ask you now to give us your name and best contact- address, phone number, and email address. Please know that we will only use this information to contact you regarding the follow up survey. Your personal information will not be linked or stored with your survey responses.
I agree to the above paragraph. Please indicate your email address as your signature.
________________________________________________________________
Signature
Name __________________________________________________________________________________
First MI Last
May we contact you by mail? Y N
Preferred Address: _____________________________________________________________________________
Address Apt. #
_____________________________________________________________________________
City State Zip
Other Address: _____________________________________________________________________________
Address Apt. #
_____________________________________________________________________________
City State Zip
May we contact you by e-mail? Y N
Campus email: _____________________________ Other email: ___________________________
May we contact you by phone? Y N
Campus/Local phone: ______________________ Cell phone: ___________________________
Work phone: ______________________
Share phone? Y N Best time to call_____________________________
May we leave you a voice mail that states we are calling from the Brothers Leading Healthy Lives program? Y N
Where should we send mail? ____Preferred mailing address ____Other mailing address
May we send you emails from the Brothers Leading Healthy Lives program? Y N
Preferred contact #? Home___ Work___ Cell___ Email___
File Type | application/msword |
File Title | HIV/AIDS Risk Reduction Interventions for African-American |
Author | cso5 |
Last Modified By | Thelma Elaine Sims |
File Modified | 2010-07-23 |
File Created | 2010-07-12 |