Form 1 Letter

OMB#: 0925-XXXX

Exp. XX/XXXX

Public reporting burden for this collection of information is estimated to average 30 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: 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.

Letter for HCHS/SOL Participant Event Ascertainment Collected from Person Physician by mail with accompanying PHQ form:

Dear Dr. (insert Physician name) ,

A patient under your care, ( insert Participant name ), is a participant of the Hispanic Community Health Study/Study of Latinos funded by NHLBI of NIH. We have permission from ( insert Participant name ) to collect the information for that study related to their personal health. A copy of a signed medical information release form signed by ( insert Participant name ) is attached.

Based on our records (SUPPLY NAME of PARTICIPANT) insert one (DIED or WAS HOSPITALIZED) in (SUPPLY MONTH), 20__. We are requesting information about the events surrounding his/her death/hospitalization because it may provide clues which will help in the fight against heart disease, stroke, diabetes, and respiratory disease.

Please complete the attached form and return it to our research center in the attached, addressed and stamped envelope. The questions concerning (NAME)’s illness and/or death. The form takes at most 30 minutes to complete using your office records. All responses are confidential an are compliant under federal guidelines with HIPPA regulations. If you have questions or would like to speak with someone at our HCHS/SOL research center the phone number is (INSERT PHONE NUMBER).

Thank you,

Institutional Investigator signature.

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