Att N

VERSIÓN EN ESPAÑOL AL REVERSO
NOTICE: Public reporting burden (or time) for this collection of information is estimated to average 2 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. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer,
Paperwork Reduction Project (0930-0110); Room 2-1057; 1 Choke Cherry Road, Rockville, MD 20857. An agency may not
conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid
OMB control number. The OMB control number for this project is 0930-0110.

OMB No.: 0930-0110
OMB Expiration Date:
xx/xx/xx

QUALITY CONTROL FORM
As part of our quality control program, we plan to contact a portion of the survey participants to
make sure that the interviewer has followed the study procedures. We only ask general
questions—no specific information is required. We sincerely appreciate your cooperation.
Please fill in the boxes below. (PLEASE PRINT CLEARLY.) Thank you.

[Your phone number will be kept confidential and will not be released to anyone other than our
quality control representatives.]
TELEPHONE
NUMBER

_

_

(Area Code)

(Telephone Number)

YOUR
ADDRESS
CITY

ZIP
CODE

STATE

BOXES BELOW MUST FIRST BE COMPLETED [IN INK] BY INTERVIEWER.
TODAY’S
DATE

M

M

_

D

D

_

1

FI
NAME
CASE
ID #

4

TIME

.
.

AM
PM

FI
ID #
_

_

_

Include
A or B!

IF respondent is 12 - 17 years old, which
adult granted permission for the interview? 
(Examples: father, mother, etc.)

[Print Parent/Guardian’s relationship to the child in this box.]