Personal Identifiers_span

ID NUMBER:

FORM CODE: IDS VERSION: A 7/02/07

Contact Occasion

SEQ #

OMB#: 0925-XXXX

Exp. XX/XXXX

Public reporting burden for this collection of information is estimated to average 07 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.

H

OMB#: 0925-XXXX

Exp. XX/XXXX

CHS/SOL Personal Identifiers_Spanish

ID NUMBER:

FORM CODE: IDS VERSION: A 7/02/07

Contact Occasion

SEQ #

Acrostic:

Administrative Information

0a. Completion Date: 0b. Staff ID: 0c. Household ID Number:

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Month Day Year (See Household Screening form, copy number exactly as seen on screener)

Instructions: Complete this form for each eligible participant. All responses are important to complete fully, including the contacts. Use location codes at end for coding address.

A. Identifying Information

1. a. Título: _______________ b. Primer nombre:

c. Segundo Nombre:

d. Apellido Paterno:

e. Apellido Materno: ______________________________________

Como parte de la información confidencial que recopilamos de los participantes del Estudio de la Salud de la Comunidad Hispana / Estudio de los Latinos, le pedimos su número de seguro social. Por favor, lea la declaración sobre la divulgación de información personal que se encuentra a continuación, la cual explica las razones por las que le estamos pidiendo su número de seguro social y que el darnos este número es voluntario de su parte.

Declaración sobre la divulgación de información personal: Le estamos pidiendo su número de seguro social porque los datos de este estudio se relacionarán con los datos que dan los proveedores de cuidados de la salud sólo con propósitos de realizar estudios sobre la salud. Esta información se mantendrá en forma confidencial de acuerdo a la Ley de Privacidad de 1974 y se usará solamente con propósitos de realizar estudios sobre la salud. El dar esta información al Estudio de la Salud de la Comunidad Hispana / Estudio de los Latinos es completamente voluntario de su parte, pero es sumamente importante para los propósitos de este estudio.

2. Número de seguro social: --

B. Participant Address/Telephone

Es muy importante para este estudio poder localizarlo(a) a usted. Por favor, díganos cuál es su dirección actual. Nosotros no le daremos su dirección a nadie más.

3. Actual dirección domiciliaria*

3.A.1. PO Box, Box &/or Route and Number
3.B.1. Street Number Prefix
3.B.2. Street Number
3.B.3. Street Number Suffix
3.C.1. Street Name Prefix
3.C.2. Street Name
3.C.3. Street Name Type
3.C.4. Street Name Suffix
3.D.1. Unit Type
3.D.2. Unit Prefix
3.D.3. Unit Identifier
3.D.4. Unit Suffix
3.E.1. Other
3.F.1. City
3.G.1. County
3.H.1. State
3.I.1. Country/Territory (Select code from list)
3.J.1. Zip Code						–

¿Cuánto tiempo ha vivido usted en esta dirección? Desde …

3.K.1. Año
3.K.2. Mes			IF UNKNOWN, ENTER 99
3.K.3. Día			IF UNKNOWN, ENTER 99

*IF THE PARTICIPANT LIVES AT SEVERAL LOCATIONS, ENTER WHERE HE OR SHE LIVES MOST. IF THE EXACT ADDRESS IS UNKNOWN, ENTER THE NAME OF THE INTERSECTION OR STREET CLOSEST TO THE HOME LOCATION IN 3.C.2. AND THE NAME OF THE BUILDING OR LOCATION IN 3.E.1.

IF THE ONLY KNOWN HOME ADDRESS IS A POST OFFICE BOX, BOX, OR ROUTE AND NUMBER, ENTER IT IN 3.A.1., BUT ALSO ENTER THE NAME OF THE INTERSECTION OR STREET CLOSEST TO THE ACTUAL HOME LOCATION IN 3.C.2. AND THE NAME OF THE BUILDING OR LOCATION IN 3.E.1.

4. Número de teléfono principal: () -

5. ¿Cuál es la mejor hora del día para llamarlo(a) a este número?

Mañana 1

Tarde 2

Noche 3

6. Número de teléfono alternativo: () -

7. ¿Cuál es la mejor hora del día para llamarlo(a) a este número?

Mañana 1

Tarde 2

Noche 3

C. Local Contact 1

8. a. Título: _______________ b. Primer nombre:

c. Segundo nombre:

d. Apellido Paterno:

e. Apellido materno: ______________________________________

9. Relación: __________________

10. Current home address of primary contact*

10.A.1. PO Box, Box &/or Route and Number
10.B.1. Street Number Prefix
10.B.2. Street Number
10.B.3. Street Number Suffix
10.C.1. Street Name Prefix
10.C.2. Street Name
10.C.3. Street Name Type
10.C.4. Street Name Suffix
10.D.1. Unit Type
10.D.2. Unit Prefix
10.D.3. Unit Identifier
10.D.4. Unit Suffix
10.E.1. Other

10.F.1. City
10.G.1. County
10.H.1. State
10.I.1. Country/Territory (Select code from list)
10.J.1. Zip Code						–

*IF THE PERSON LIVES AT SEVERAL LOCATIONS, ENTER WHERE HE OR SHE LIVES MOST. IF THE EXACT ADDRESS IS UNKNOWN, ENTER THE NAME OF THE INTERSECTION OR STREET CLOSEST TO THE HOME LOCATION IN 10.C.2. AND THE NAME OF THE BUILDING OR LOCATION IN 10.E.1.

IF THE ONLY KNOWN HOME ADDRESS IS A POST OFFICE BOX, BOX, OR ROUTE AND NUMBER, ENTER IT IN 110.A.1., BUT ALSO ENTER THE NAME OF THE INTERSECTION OR STREET CLOSEST TO THE ACTUAL HOME LOCATION IN 110.C.2. AND THE NAME OF THE BUILDING OR LOCATION IN 110.E.1.

11. Teléfono: () -

D. Local Contact 2

12. a. Título: _______________ b. Primer nombre:

c. Segundo nombre:

d. Apellido Paterno:

e. Apellido materno: ______________________________________

13. Relación: __________________

14. Current home address of secondary contact*

14.A.1. PO Box, Box &/or Route and Number
14.B.1. Street Number Prefix
14.B.2. Street Number
14.B.3. Street Number Suffix
14.C.1. Street Name Prefix
14.C.2. Street Name
14.C.3. Street Name Type
14.C.4. Street Name Suffix
14.D.1. Unit Type
14.D.2. Unit Prefix
14.D.3. Unit Identifier
14.D.4. Unit Suffix
14.E.1. Other
14.F.1. City
14.G.1. County
14.H.1. State
14.I.1. Country/Territory (Select code from list)
14.J.1. Zip Code						–

15. Teléfono: () -

*If the person lives at several locations, enter where he or she lives most. If the exact address is unknown, enter the name of the intersection or street closest to the home location in 14.C.2. and the name of the building or location in 14.E.1.

If the only known home address is a post office box, box, or route and number, enter it in 14.A.1., but also enter the name of the intersection or street closest to the actual home location in 14.C.2. and the name of the building or location in 14.E.1.

E. Local Contact 3

12. a. Título: _______________ b. Primer nombre:

c. Segundo nombre:

d. Apellido Paterno:

e. Apellido materno: ______________________________________

17. Relación: __________________

18. Current home address of third contact*

18.A.1. PO Box, Box &/or Route and Number
18.B.1. Street Number Prefix
18.B.2. Street Number
18.B.3. Street Number Suffix
18.C.1. Street Name Prefix
18.C.2. Street Name
18.C.3. Street Name Type
18.C.4. Street Name Suffix
18.D.1. Unit Type
18.D.2. Unit Prefix
18.D.3. Unit Identifier
18.D.4. Unit Suffix
18.E.1. Other
18.F.1. City
18.G.1. County
18.H.1. State
18.I.1. Country/Territory (Select code from list)
18.J.1. Zip Code						–

19. Teléfono: () -

*If the person lives at several locations, enter where he or she lives most. If the exact address is unknown, enter the name of the intersection or street closest to the home location in 18.C.2. and the name of the building or location in 18.E.1.

If the only known home address is a post office box, box, or route and number, enter it in 18.A.1., but also enter the name of the intersection or street closest to the actual home location in 18.C.2. and the name of the building or location in 18.E.1.

Location Codes for Question 3I1, 10I1, 14I1, and 18I1

1. Afghanistan

2. Anguilla

3. Antigua and Barbuda

4. Argentina

5. Aruba

6. Australia

7. Austria

8. Bangladesh

9. Belgium

10. Belize

11. Bolivia

12. Brazil

13. Canada

14. Chile

15. China

16. Colombia

17. Costa Rica

18. Cuba

19. Czech Republic

20. Denmark

21. Dominican Republic

22. Ecuador

23. El Salvador

24. Finland

25. France

26. Germany

27. Great Britain

28. Greece

29. Guam

30. Guatemala

31. Haiti

32. Holland

33. Honduras

34. Hungary

35. India

36. Indonesia

37. Iran

38. Iraq

39. Ireland

40. Israel

41. Italy

42. Japan

43. Korea

44. Lebanon

45. Malaya

46. Mexico

47. New Zealand

48. Nicaragua

49. Norway

50. Pakistan

51. Panama

52. Paraguay

53. Peru

54. Philippines

55. Poland

56. Portugal

57. Puerto Rico

58. Russia

59. South Africa

60. Spain

61. Sweden

62. Switzerland

63. United States

64. Uruguay

65. Venezuela

66. Virgin Islands

67. Other

99 Unknown/refused

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