Form Approved
OMB Control No. 0920-1140
Exp. Date: 10 / 31 / 2017
Attachment G. Contact information form
Date: _______________
Participant initials: ____________
Interviewer initials: ____________
Recruitment site: __Home __Clinic
First Name: ____________
Paternal Surname: ____________
Maternal surname: ____________
Cell phone number: ____________
Cell phone company: ____________
Alternative phone number: ____________
Email: ____________
Alternative email: ____________
Address: ________________________________________________________________________
Municipality: ____________
Zip code: ____________
Preferred contact method: ____________
Other Contact method: ____________
Secondary contact first name: ____________
Paternal last name: ____________
Maternal last name: ____________
Relationship: ____________
Public reporting burden of 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. 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. 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 NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-1140
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Modified | 0000-00-00 |
File Created | 2021-01-22 |