E_Contact Update Request Form_final 11.8.19

Attachment E - Contact Update Request Letter and Form

OMB Control No: ____-____

Expiration Date: __/__/____

[Address]

[Date]

Dear < name>,

Hello again from the Building Evidence on Employment Strategies for Low-Income Families (BEES) study team. It’s time to update your contact information!

In <RA MONTH/YEAR>, you applied to receive employment services through <BEES program>. At that time, you also agreed to participate in a research study.

Researchers at MDRC, Abt Associates, and MEF Associates are conducting the BEES study for the U.S. Department of Health and Human Services, or HHS. HHS would like to learn more about what types of services help you and other people like you find and keep jobs. When you agreed to be in the study, you also agreed to let researchers contact you every few months. The purpose of these contacts is to make sure we have your correct phone number, email, and street address in our secure database.

Your updated contact information helps make sure we are able to interview you and see how your life has changed since you first enrolled in the study. Your experiences are unique and we want to be sure you are represented. We can’t interview you if we can’t contact you! To make sure that your information in our records is correct, please verify your contact information on the next page. You can do this in one of three ways.

1. Make any changes online by visiting [INSERT WEBLINK].

   1. Enter your unique PIN <BEESID>.

   2. Make any needed updates to your phone number, address, or email.

   3. If there are no changes, check the box that says “This is correct.”

2. Fill out the enclosed form.

   1. Make any needed updates to your phone number, address, or email.

   2. If there are no changes, check the box that says “This is correct.”

   3. Return the updated form in the postage paid envelope provided.

3. Call the BEES study toll-free line XXXXXXXX.

   1. Have your unique PIN <BEESID> when you call.

   2. Report any updates to your phone number, address or email.

   3. If there are no changes, report that your information is correct.

It should take about 5 minutes for you to verify your contact information. When we hear from you, we will send you a $5 gift card. Your participation in this study is completely voluntary. You can choose not to respond at any time. However, your continued participation in this study is very important and greatly appreciated. Any information you provide will be kept private.

Thank you for being part of this important study! Please contact us toll-free at XXX-XXX-XXXX or [EMAIL] us if you have any questions.

Sincerely,

<ABT SURVEY DIRECTOR >

The Paperwork Reduction Act Statement: This collection of information is voluntary and will be used to understand programs that aim to improve employment outcomes for low-income adults. Public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, 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. The OMB number and expiration date for this collection are OMB #: XXXX-XXXX, Exp: XX/XX/XXXX. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to Dan Bloom (MDRC); 200 Vesey Street, 23^rd Floor, New York, NY 10281-2103.

Abt Associates Survey Director

Participant Records Verification

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:

 _{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:

 _{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:

 This is correct

 _{This is not correct (print correct information below)}

Enter Updated Address:

In care of:

^Last _First ^M.I.

Street Address Apartment/Unit #

_City ^{State ZIP Code}

We have your primary PHONE NUMBER as:

 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? This could be regular text or automated text.

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

(We may text you to confirm an appointment, to let you know that we are trying to reach you, or to request that you return your updated contact information form,)

We have your primary EMAIL Address as:

 This is the best email to reach me

 _{This is not the best email to reach me (print correct information below)}

_{Enter best EMAIL Address: @:}

What is your preferred method of contact?

 Call home number  Call cell number  Email Text Message 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 : Relationship:

Address:

Primary phone number: Alternative phone number is:

 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:

Address:

First & Last Relationship

_{Street Address & Apartment/Unit # City State ZIP Code}

Primary Phone: _{( )} Alternate Phone: _{( )}

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

_{Email: @:}

Secondary Contacts: Person 2

Name : Relationship:

Address:

Primary phone number: Alternative phone number is:

 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:

Address:

First & Last Relationship

_{Street Address & Apartment/Unit # City State ZIP Code}

Primary Phone: _{( )} Alternate Phone: _{( )}

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

_{Email: @:}

Secondary Contacts: Person 3

Name : Relationship:

Address:

Primary phone number: Alternative phone number is:

 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:

Address:

First & Last Relationship

_{Street Address & Apartment/Unit # City State ZIP Code}

Primary Phone: _{( )} Alternate Phone: _{( )}

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

_{Email: @:}

The Paperwork Reduction Act Statement: This collection of information is voluntary and will be used to understand programs that aim to improve employment outcomes for low-income adults. Public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, 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. The OMB number and expiration date for this collection are OMB #: XXXX-XXXX, Exp: XX/XX/XXXX. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to Dan Bloom (MDRC); 200 Vesey Street, 23^rd Floor, New York, NY 10281-2103.