Form 2 Residential Response

OMB#: 0925-XXXX

Exp. XX/XXXX

Public reporting burden for this collection of information is estimated to average 1 minute 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-XXXX). Do not return the completed form to this address.

H

ispanic Community Health Study/Study of Latinos

We are looking for adults between the ages of 18 and 74, of Hispanic origin to participate in a research study. Please take a few minutes to answer the following questions and return to us either by mail or by fax.

• No one in this household is of Hispanic origin

• No one is between 18– 74 years of age

• I am interested in possible participation, and I am of Hispanic origin between 18 – 74 years of age.

Please contact me at one of the following:

Name:

Phone number: ( )

Email:

If you wish to hear more about our study, please call us at one of the following numbers: [phone #], [additional phone #], fax: [fax #], or email at: [email address]

Thank you so much!

HCHS/SOL Staff