Appendix X - Contact Information Form for Paycheck Plus site

Appendix X

The Paperwork Reduction Act Burden Statement: This collection of information is voluntary and will be used for the Paycheck Plus Study. Public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. 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 collection is 0970-0413 and it expires 9/30/2017.

PARTICIPANT AND ADDITIONAL PERSON CONTACT INFORMATION

Thank you very much for your time today. To help us be able to get back in touch with you in the future, we would like to collect your contact information (name, mailing address, telephone number, and email address), as well as contact information for three people who will always know how to reach you but are at a different address than you. This information will be kept strictly private and will only be used if we are unable to contact you.

PARTICIPANT CONTACT INFORMATION
First Name		Middle Name	Last Name
Street address
Apt. No.	City				State	Zip Code
Is this address the best address to mail something to you? Yes No
If not, what address should we use if we mail something to you?
Street address
Apt. No.	City				State	Zip Code
What is your home phone number? ( ) –				What is your work phone number? ( ) –
What is your cell phone number? ( ) –				May we send text messages to your cell phone? Yes No
Do you have an email address? Yes No If Yes, what is it?
Do you have a Facebook account? Yes No If Yes, is your Facebook account linked to the email provided above?  If No, provide additional email address.
May we contact you at your Facebook account in the future? Yes No

CONTACT # 1: Could you tell us the name of a primary person who does not live with you and will always know how to contact you?
First Name		Middle Name			Last Name			Suffix
Street address
Apt. No.	City					State	Zip Code
Home Tel. No. ( ) –			Relationship (friend, relative, please specify)
Cell Tel. No. ( ) –				Work Tel. No. ( ) –
Does he/she have an email address? Yes No If Yes, what is it?
Does he/she have a Facebook account? Yes No If Yes, what name does he/she use on his/her Facebook profile (for example, does he/she use a nickname or shortened first name)?
May we contact him/her at his/her Facebook account in the future? Yes No

CONTACT # 2: Could you tell us the name of a second person who does not live with you and will always know how to contact you?
First Name		Middle Name		Last Name				Suffix
Street address
Apt. No.	City					State	Zip Code
Home Tel. No. ( ) –			Relationship (friend, relative, please specify)
Cell Tel. No. ( ) –					Work Tel. No. ( ) –
Does he/she have an email address? Yes No If Yes, what is it?
Does he/she have a Facebook account? Yes No If Yes, what name does he/she use on his/her Facebook profile (for example, does he/she use a nickname or shortened first name)?
May we contact him/her at his/her Facebook account in the future? Yes No

CONTACT # 3: Could you tell us the name of a third person who does not live with you and will always know how to contact you?
First Name		Middle Name		Last Name				Suffix
Street address
Apt. No.	City					State	Zip Code
Home Tel. No. ( ) –			Relationship (friend, relative, please specify)
Cell Tel. No. ( ) –					Work Tel. No. ( ) –
Does he/she have an email address? Yes No If Yes, what is it?
Does he/she have a Facebook account? Yes No If Yes, what name does he/she use on his/her Facebook profile (for example, does he/she use a nickname or shortened first name)?
May we contact him/her at his/her Facebook account in the future? Yes No

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