Form 1 Shadow Sample

Population Assessment of Tobacco and Health (PATH) Study (NIDA)

Attachment 3j - English
PATH Study Data Collection Instruments:
Followup Tracking Participant Information Form –
Shadow Sample Youth
June 18, 2013

Population Assessment of Tobacco and Health (PATH) Study (NIDA)

OMB Control Number: 0925-0664
Expiration Date: 11/30/2015

FRT2c –Parent of Youth under Age 12 (Shadow Sample Member) Participant
Information Form
Parent Information Form
This form is for updating contact information on [YOUTH’S_NAME]’s parent. If you’ve moved or
any of your contact information has changed since [YOUTH’S_NAME] last participated in the
Population Assessment of Tobacco and Health (PATH) Study,* please give us your new contact
information by either:

(1)
(2)

Filling out this form and returning it using the enclosed postage-paid envelope; OR
Completing the form online at www.pathstudyinfo.nih.gov using your password:
[PASSWORD]. (If you have a smartphone, you can scan the QR code below to visit the
website.)

As a thank you for completing this form, an additional $5 will be put on [YOUTH’S_NAME]’s
PATH Study debit card (up to $10 a year). (Please contact us toll-free at 1-888-311-1819, if the card
was misplaced.)
If none of your contact information has changed, simply check this box:



PARENT’S NEW CONTACT INFORMATION. PLEASE PRINT CLEARLY.
NAME: ____________________________________________________________________________
FIRST
MI
LAST
STREET ADDRESS:_________________________________________________________________
STREET
APT. #
___________________________________________________________________________________
CITY
STATE
ZIP

PARENT’S MAILING ADDRESS (IF DIFFERENT FROM THE STREET ADDRESS ABOVE):
STREET ADDRESS:_________________________________________________________________
STREET
APT. #
___________________________________________________________________________________
CITY
STATE
ZIP
* This study is sponsored by the National Institutes of Health (NIH), in partnership with the Food and Drug
Administration (FDA).

Population Assessment of Tobacco and Health (PATH) Study (NIDA)

PARENT’S TELEPHONE NUMBER(S):
HOME:|__|__|__|-|__|__|__|-|__|__|__|__|
CELL:|__|__|__|-|__|__|__|-|__|__|__|__|

PARENT’S PREFERRED EMAIL ADDRESS: _________________________ _ @ ______________
How would you prefer that we contact you? (Select all that apply)


HOME PHONE



CELL PHONE (VOICE)



PREFERRED EMAIL



CELL PHONE (TEXTING)

Do you anticipate moving or relocating either permanently or temporarily in the next 6 to 12
months?


NO



YES – WHERE?__________________________________________________

Does [YOUTH’S_NAME] anticipate moving or relocating either permanently or temporarily in
the next 6 to 12 months?


NO



YES – WHERE?__________________________________________________

Thank you for your time.
Public reporting burden for this collection of information is estimated to average 8 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 (0925-0664). Do not return
the completed form to this address.

DCN {DCN_BARCODE_3of9}

www.pathstudyinfo.nih.gov

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