MI Contact Info Sheet

Attachment 4d. Michigan Contact Information Sheet

Attached to Contact Information Sheet to signed Consent Form – Contact Information is verified after the Informed Consent form is signed by the participant and before the biomonitoring interview begins.

Script: I also need to verify we have the correct contact information for you. Would you look at this sheet to see if we need to make any changes in your phone, address, or email address?

If information is correct, write “No corrections” on the Contact Information sheet and initial it. Attach it to the Participant Consent signature page. Okay. Let’s move on to the questionnaire.

If information is incorrect, write the corrections on the Contact Information sheet and initial it. Attach it to the Participant Consent signature page. Okay. Let’s move on to the questionnaire.

Public reporting burden of this collection of information is estimated to average 2 minutes per response for total participation, 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 person is not required to respond to 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, MS D-74, Atlanta, GA 30333, ATT

N: PRA (0923-XXXX).

Contact Information Sheet
Study ID: 123456	Contact Information	Updated Contact Information
Street Number	123
Street Name	Main St.
Unit	2
PO Box
City	Detroit
State	MI
Zip Code	48000
email address	michigan@michigan.gov
Best Phone Number	313.123.4567
Phone 1 (cell)	313.987.6543
Phone 2 (work)