Participant Contact Information Form

Appendix C

Contact Information Form

Appendix C

Contact Information Form

Updated 10.3.12

STED Contact Information Sheet

STED PARTICIPANT AND ADDITIONAL CONTACT INFORMATION

To help us be able to get back in touch with you in the future, we would like to collect your contact information (name, mailing address, telephone number, and email address), as well as contact information for three people who will always know how to reach you but live at a different address than you. This information should take approximately five minutes to complete and will be kept private to the extent permitted by law. It will only be used if we are unable to contact you.

PARTICIPANT CONTACT INFORMATION
First Name		Middle Name			Last Name				Date of Birth
Street address
Apt. No.	City						State	Zip Code
Is this address the best address to mail something to you? Yes No
If not, what address should we use if we mail something to you?
Street address
Apt. No.	City						State	Zip Code
What is your home phone number? ( ) –						What is your work phone number? ( ) –
What is your cell phone number? ( ) –						May we send text messages to your cell phone? Yes No Do you pay for text messages? Yes No
Do you have an email address? Yes No If Yes, what is it?
Do you have a Facebook account? Yes No If Yes, may we contact you at your Facebook account in the future? Yes No If Yes, what name do you use on your Facebook profile (for example, do you use a nickname or shortened first name)?
CONTACT # 1: Could you tell us the name of a primary person who does not live with you and will always know how to contact you?
First Name		Middle Name			Last Name				Suffix
Street address
Apt. No.	City						State	Zip Code
Home Tel. No. ( ) –			Relationship (friend, relative, please specify)
Cell Tel. No. ( ) –				Work Tel. No. ( ) –
Does he/she have an email address? Yes No If Yes, what is it?
Does he/she have a Facebook account? Yes No If Yes, may we contact him/her at his/her Facebook account in the future? Yes No If Yes, what name does he/she use on his/her Facebook profile (for example, does he/she use a nickname or shortened first name)?
CONTACT # 2: Could you tell us the name of a second person who does not live with you and will always know how to contact you?
First Name		Middle Name			Last Name				Suffix
Street address
Apt. No.	City						State	Zip Code
Home Tel. No. ( ) –			Relationship (friend, relative, please specify)
Cell Tel. No. ( ) –						Work Tel. No. ( ) –
Does he/she have an email address? Yes No If Yes, what is it?
Does he/she have a Facebook account? Yes No If Yes, may we contact him/her at his/her Facebook account in the future? Yes No If Yes, what name does he/she use on his/her Facebook profile (for example, does he/she use a nickname or shortened first name)?
CONTACT # 3: Could you tell us the name of a third person who does not live with you and will always know how to contact you?
First Name		Middle Name			Last Name				Suffix
Street address
Apt. No.	City						State	Zip Code
Home Tel. No. ( ) –			Relationship (friend, relative, please specify)
Cell Tel. No. ( ) –						Work Tel. No. ( ) –
Does he/she have an email address? Yes No If Yes, what is it?
Does he/she have a Facebook account? Yes No If Yes, may we contact him/her at his/her Facebook account in the future? Yes No If Yes, what name does he/she use on his/her Facebook profile (for example, does he/she use a nickname or shortened first name)?

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