Revised Form

OMB Control Number: 0925-0664

Expiration Date: 11/30/2015

Adult Information Form

If you’ve moved or any of your contact information has changed since you last participated in the Population Assessment of Tobacco and Health (PATH) Study,* please give us your new contact information by either:

1. Filling out this form and returning it using the enclosed postage-paid envelope; OR

2. Completing the form online by logging into www.pathstudyinfo.nih.gov. (If you have a smartphone, you can scan the QR code below to visit the website.)

As a thank you for completing this form, you’ll receive an additional $5 on your 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: 

YOUR NEW CONTACT INFORMATION. PLEASE PRINT CLEARLY.

NAME:

FIRST MI LAST

STREET ADDRESS:

STREET APT. #

CITY STATE/PROVINCE ZIP

COUNTRY

YOUR NEW MAILING ADDRESS (IF DIFFERENT FROM THE STREET ADDRESS ABOVE):

STREET ADDRESS:

STREET APT. #

CITY STATE/PROVINCE ZIP

COUNTRY

* This study is sponsored by the National Institutes of Health (NIH), in partnership with the Food and Drug Administration (FDA).

YOUR NEW TELEPHONE NUMBER(S):

HOME:|__|__|__|-|__|__|__|-|__|__|__|__|

CELL:|__|__|__|-|__|__|__|-|__|__|__|__|

YOUR NEW PREFERRED EMAIL ADDRESS:

_____________________________________________________@

In addition to mail, how would you prefer that we contact you? (Select all that apply)

 HOME PHONE

 CELL PHONE (VOICE)  CELL PHONE (TEXTING)

 PREFERRED EMAIL

NEW CONTACT INFORMATION FOR SOMEONE WHO WILL ALWAYS KNOW HOW TO LOCATE YOU. PLEASE PRINT CLEARLY.

NAME:

FIRST MI LAST

TELEPHONE NUMBER(S):

HOME:|__|__|__|-|__|__|__|-|__|__|__|__|

CELL:|__|__|__|-|__|__|__|-|__|__|__|__|

PREFERRED EMAIL ADDRESS:

_____________________________________________________@

STREET ADDRESS:

STREET APT. #

CITY STATE/PROVINCE ZIP

COUNTRY

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

 NO  YES

IF YES, WHEN WILL YOU MOVE?

IF YES, PLEASE PROVIDE YOUR NEW CONTACT INFORMATION

STREET ADDRESS:

STREET APT. #

CITY STATE/PROVINCE ZIP

COUNTRY

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.

FRT2_V0