Appendix F_Previously Approved Contact Info. Update Form

Supporting Statement for OMB Clearance Request

Appendix F: Previously Approved Contact Update Form

Pathways for Advancing Careers and Education (PACE) – Follow-up Data Collection

OMB No. 0970-0397

March 2017

Submitted by:

Nicole Constance

Office of Planning, Research
and Evaluation

Administration for Children
and Families

U.S. Department of Health and Human Services

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).

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

Do we have your permission to contact you via text message to your cell phone? Please answer yes or no for permission to send a regular text and to send an automated text. (An automated text message is a prewritten message that is sent at a later date such as a text that reminds you to complete a form or call to set up an appointment.)

 Yes, you may contact me via text message  Yes, you may contact me via automated text message to my cell phone to my cell phone

 _{No, you may not contact me via text message}  _{No, you may not contact me via automated text to my cell phone message to your cell phone}

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