Locator Form (UNCG)

HIV/AIDS Risk Reduction Interventions for African-American Heterosexual Men

0920-10CM_Att3f_Locator Form (UNCG)

Locator Form (UNCG)

OMB: 0920-0873

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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)

Keep In Touch Form (KIT FORM)


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 Typeapplication/msword
File TitleHIV/AIDS Risk Reduction Interventions for African-American
Authorcso5
Last Modified ByThelma Elaine Sims
File Modified2010-07-23
File Created2010-07-12

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