Appendix E_Previously Approved_Contact Update Form

Supporting Statement for OMB Clearance Request

Appendix E: Previously Approved Contact Update Form

National Implementation Evaluation of the Health Profession Opportunity Grants (HPOG) to Serve TANF Recipients and Other Low-Income Individuals and HPOG Impact Study

0970-0394

March 2017

Submitted by:

Office of Planning,
Research & Evaluation

Administration for Children & Families

U.S. Department of Health
and Human Services

Federal Project Officer:

Nicole Constance

Participant Contact Update Form

Please verify that the information we have on file for you is accurate. Return this form in the included envelope (postage paid).

Paperwork Reduction Act (PRA) Statement: Your participation in this information collection is voluntary. 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 0970-0394 and it expires xx/xx/xxxx. If you have comments regarding this collection of information, including suggestions for reducing this burden, please send them to [Contact Name]; [Contact Address]; Attn: OMB-PRA (0970-0394).

Personal Information Verification

We have your NAME as: «First_Name» «Middle_Initial» «Last_Name»  This is correct  This is not correct (print correct information below)

Enter updated NAME: Full Name:

Last

First

M.I.

We have your ADDRESS as: «Street» «Apt» «City» «State» «Zip» - «Zip5»  This is correct  This is not correct (print correct information below)

Enter Updated Address:

Street Address

Apartment/Unit #

City

State

ZIP Code

We have your MAILING ADDRESS as: «Street» «Apt» «City» «State» «Zip» - «Zip5»

Enter Updated Address:

Last

First

M.I.

Street Address

Apartment/Unit #

City

State

ZIP Code

We have your primary PHONE NUMBER as: «Primary_Phone».  This is the best number to reach me  This is not the best number to reach me (print correct information below)

Enter best PHONE NUMBER: Primary Phone:

( )

Alternate Phone:

( )

 cell  home  work other  cell  home  work other

Secondary Contacts: Person 1

Please check below and correct the names, addresses and telephone numbers of the three people you previously provided us who are living outside your household and usually know where to reach you. The name, address, phone #s and relationship to you of best person who will always know where to reach you is: Name : Address: Primary phone number:  This is the best person to reach me  This is NOT the best person to reach me (print correct information below) Enter Updated contact information name, address, relationship and phone numbers.

Full Name:

First & Last

Relationship

Address:

Street Address & Apartment/Unit # City State

ZIP Code

Primary Phone:

( )

Alternate Phone:

( )

 cell  home  work other  cell  home  work other

Secondary Contacts: Person 2
Name : Address: Primary phone number:  SECOND person contact information is correct  SECOND person contact information is NOT correct (print correct information below) Enter Updated person 2 name, address, relationship and phone numbers.
Full Name:
	First & Last			Relationship
Address:
	Street Address & Apartment/Unit # City State					ZIP Code
Primary Phone:		( )	Alternate Phone:		( )

 cell  home  work other  cell  home  work other

Secondary Contacts: Person 3
Name : Address: Primary phone number:  THIRD person contact information is correct  THIRD person contact information is NOT correct (print correct information below) Enter Updated person 3 name, address, relationship and phone numbers.
Full Name:
	First & Last			Relationship
Address:
	Street Address & Apartment/Unit # City State					ZIP Code
Primary Phone:		( )	Alternate Phone:		( )

 cell  home  work other  cell  home  work other