ASD - PRE-ENROLLMENT_Invitation Packet/Response Card (Mother)

Attachment 19.g.

Form Approved

OMB NO. 0920-XXXX

Exp. Date XX/XX/2020

Response Card

Front:

Study to Explore Early Development (SEED)

CDC and HHS Logos and/or Site Institution Logo

Picture

Back:

<site specific source code>

We hope you and your child will take part in SEED!

Please contact us to learn more.

You are under no obligation to take part in the study if you contact us. But, you will receive a $10 <site specific: money order/cash card/Visa card, etc>, if you contact us and answer a few short questions -- even if you decide not to take part in SEED.

Step 1: Check one of the boxes below

YES, please contact me. I would like to learn more about SEED

NO, I am not interested in learning more about SEED

Follow Step 2 or Step 3:

Step 2: Complete the following information and mail this card to us in the pre-paid envelope.

Name:_______________________________

Address Telephone numbers

______________________________ home__________________________

_______________________________ cell __________________________

_______________________________ other __________________________

Email __________________________

I prefer to be reached by (circle one): Best time to reach me is (circle one):

Telephone E-mail Morning Afternoon Early Evening

Step 3: If you prefer, you can contact us.

• by phone at <number>,

• by text at <number>,

• by emailing us at <email address>.

If you text or email us, give us your name and a telephone number or email address where we can reach you.

Version 9-2015 1