#1 - Tracking Survey

ID NUMBER LABEL

Early Head Start Follow-up Study
Contact Information Update

• Thank you for taking the time to update your contact information for the Early Head Start
Follow-up Study.
• Please remember all the information you provide here is private and will be shared ONLY
with researchers working on the Early Head Start Follow-up Study.
• If you are contacted in the future for the study, you can decide at that time whether or not to
take part.
• When you are finished completing this form, please use the postage paid return envelope
provided to mail it to us.
• When we receive your updated contact information, we will send you a check for $15 to
thank you for your time.
• If you have any questions, please call us on the study toll-free number at:

(888) 800-3748.
Thank you!

The valid OMB control number for this information collection is XXXX-XXXX.

INSTRUCTIONS
•
•
•

1.

Draw an X inside the boxes next to your answers.
Please print your answer when a question asks you to write something in.
If you make a mistake, cross it out and draw a circle around the correct answer.

Please take a look at the names printed on the letter that came with this form.
Is your name correct?
… Yes
… No Æ What is your current name?
First

2.

Middle

Last

Is the child’s name correct?
… Yes
… No Æ What is the child’s current name?
First

3.

Middle

Last

Are you still this child’s primary caregiver?
… Yes Æ PLEASE CONTINUE TO THE NEXT QUESTION (#4)
… No Æ PLEASE SKIP TO SECTION 2 (PAGE 5)

4.

What is your current home address?
Street

Apt. Number

City

5.

State

Zip Code

Do you receive mail at this address?
… Yes
… No Æ Where do you receive mail?
Street

Apt. Number

City

State

PAGE 1

Zip Code

6.

What is the best phone number to reach you on?
( _______ ) ________ --- ______________

7.

… Home

… Work

… Other: _____________

What other phone numbers could we call you on?
( _______ ) ________ --- ______________
( _______ ) ________ --- ______________
( _______ ) ________ --- ______________

8.

… Cell

… Cell

… Home

… Work

… Other: _____________

… Cell

… Home

… Work

… Other: _____________

… Cell

… Home

… Work

… Other: _____________

What is your email address? … Mark this box if you do not have email.

__________________________ @ _______________________

9.

If you work outside the home, where do you work? … Mark this box if you do not work
outside the home.
Company Name

Street

City

State

Zip Code

Phone Number

( __________ ) ___________ --- __________________ Extension: ___________

10. What school does the child attend? What grade is the child in as of Spring 2011?
… Mark this box if the child is not currently in school.
School Name

City

PAGE 2

Grade

11. Do you have any plans to move in the next year?
… Yes Æ PLEASE CONTINUE TO THE NEXT QUESTION (#11a)
… No Æ PLEASE SKIP TO QUESTION #12
11a. If you expect to move, when do you expect to move?
Approximate Date of Move (Month and Year)

11b. If you expect to move, where do you expect to move?
City

State

Country

12. In case we are unable to reach you in the future, please give us the names and
contact information of three close relatives or friends who are likely to know how to
contact you. We will only contact these people if we are unable to contact you
directly.
1st Contact:
First Name

Gender

Middle Initial

Preferred Language

Last Name

Relationship to You

… Male

… English

… Your parent

… Your sister/brother

… Female

… Spanish

… A friend

… A former spouse

… Other: _____________

… A current spouse

… Someone else: _________________

Street Address

Apt. Number

City

State

Best Phone Number

( __________ ) ___________ --- ___________________
Alternate Phone Number

( __________ ) ___________ --- ___________________

PAGE 3

Zip Code

… Cell

… Home

… Work

… Other: ___________

… Cell

… Home

… Work

… Other: ___________

2nd Contact:
First Name

Gender

Middle Initial

Preferred Language

Last Name

Relationship to You

… Male

… English

… Your parent

… Your sister/brother

… Female

… Spanish

… A friend

… A former spouse

… Other: _____________

… A current spouse

… Someone else: _________________

Street Address

Apt. Number

City

State

Best Phone Number

( __________ ) ___________ --- ___________________
Alternate Phone Number

( __________ ) ___________ --- ___________________

Zip Code

… Cell

… Home

… Work

… Other: ___________

… Cell

… Home

… Work

… Other: ___________

3rd Contact:
First Name

Gender

Middle Initial

Preferred Language

Last Name

Relationship to You

… Male

… English

… Your parent

… Your sister/brother

… Female

… Spanish

… A friend

… A former spouse

Other: _____________

… A current spouse

… Someone else: _________________

Street Address

Apt. Number

City

State

Best Phone Number

( __________ ) ___________ --- ___________________
Alternate Phone Number

( __________ ) ___________ --- ___________________

Zip Code

… Cell

… Home

… Work

… Other: ___________

… Cell

… Home

… Work

… Other: ___________

Thank you for the updated information. Please use the postage paid return envelope
provided to mail this form to us. When we receive it, we will send you a check for $15.
You should receive it in two to three weeks.
Thank you for taking part in the Early Head Start Follow-up Study!

PAGE 4

SECTION 2
PLEASE COMPLETE IF YOU ARE NO LONGER THE CHILD’S PRIMARY CAREGIVER

1.

Who is this child’s primary caregiver now? (What is his/her name)?
… Mark this box if you do not know.
First

2.

Middle

Last

What is this person’s relationship to the child?
Relationship to Child

3.

… Parent

… Non-relative foster parent

… Grandparent

… Other non-relative

… Other relative

… Someone else: ___________________________

About when did this person become the child’s primary caregiver?
Approximate Date (Month and Year)

4.

What is the best phone number to reach this person on?
( ________ ) ________ --- _________________

… Cell

… Home

… Work

… Other: _________

5. Do you have any other phone numbers for this person?
( ________ ) ________ --- _________________
( ________ ) ________ --- _________________
( ________ ) ________ --- _________________

PAGE 5

… Cell

… Home

… Work

… Other: _________

… Cell

… Home

… Work

… Other: _________

… Cell

… Home

… Work

… Other: _________

6. What is this person’s email address? … Mark this box if you do not have email.

__________________________ @ _______________________

7. What is the child’s current home address?
Street

Apt. Number

City

State

Zip Code

8. What is the child’s permanent home address? … Same as current home address
Street

Apt. Number

City

State

Zip Code

9. What school does the child attend? What grade is the child in as of Spring 2011?
… Mark this box if the child is not currently in school.
School Name

City

Grade

Thank you very much for your help.
If you are in contact with the child’s new primary caregiver, we’d appreciate it if you
could give him/her our toll-free number:1-888-800-3748 and let him/her know we are
trying to reach him/her about the study.
Please use the postage paid return envelope provided to mail this form to us. When we
receive it, we will send you a check for $15. You should receive it in two to three weeks.
Thank you for taking part in the Early Head Start Follow-up Study!

PAGE 6

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it
displays a valid OMB control number. The time required to complete this information collection is estimated to average 15
minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and
complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to: XXXXXX