Youth 1st, 2nd, and; 3rd (Male, Rural Smokeless) follow up questionnaire

CaseID

Attachment 33_R: Panel Maintenance Update Form - 18

Form Approved

OMB No. 0910-0753

Exp. Date 09/30/2019

FDA Health and Media Study

Contact Information Update Form

Please complete Parts 1 and 2 below and mail this form back to us in the postage-paid envelope provided.

PART 1. CURRENT CONTACT INFORMATION ON RECORD

Please review the current contact information we have for you below, cross through anything that is incorrect, and write your new information in the space provided. If all of the information is correct, please check the “Contact Information Correct” box and complete PART 2.

CURRENT CONTACT INFORMATION: UPDATED CONTACT INFORMATION:

Participant Name

Address1 Address2

City, State Zip

Telephone:

Email Address:

CONTACT INFORMATION CORRECT

PART 2. CONTACT INFORMATION IF YOU PLAN TO MOVE

Do you plan to move in the next 6 months? Yes No

If you plan to move in the next 6 months and know your new address and telephone number, please enter it in the space below.

If you plan to move and do not know your new address and telephone number, please provide a phone number we can use to reach you.

Date you plan to move: ____________________________________________

Address: ________________________________________________________

City: _______________________________ State _________ Zip___________

Phone: (____) _________________ (circle one): Home Work Cell phone

Thank you for your assistance! This information will be kept confidential.

OMB No: 0910-0753 Expiration Date: 09/30/2019

Paperwork Reduction Act Statement: The public reporting burden for this collection of information has been estimated to average 3 minutes per response. Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing burden to PRAStaff@fda.hhs.gov.

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