Contact information form for parents of youth younger than 18 (C.3)

Attachment C.3

Contact Information Form for Parents of Youth Younger Than 18

Contact Information Form for Parents of Minors

RTI staff would like to contact some participants in this study to ask for their feedback about the project. If your child is selected for a feedback interview, RTI will contact you first to ask for your permission. Participation in the feedback interview is voluntary. To help RTI reach you, please complete this form with your current contact information. This information will be kept private. You do not have to complete this form for your child to participate in the study.

[PLEASE PRINT] Your Name: ____________________________________

Child’s Name: ____________________________________

Mailing Address: ____________________________________

____________________________________

Email Address: ____________________________________

Home Phone #: (_____)_____________________________

Cell Phone #: (_____)_____________________________

Work Phone #: (_____)_____________________________

Please provide the information of one other person (like a friend or relative) who will always know how to contact you in the event that your contact information changes.

[PLEASE PRINT]

Name: _____________________________________________________________

Relationship to you: _____________________________________________________________

Mailing Address: _____________________________________________________________

Email Address: _____________________________________________________________

Home Phone #: (_____)________________________________________________________

Cell Phone #: (_____)________________________________________________________

Work Phone #: (_____)_______________________________________________________

The Paperwork Reduction Act Statement: Public reporting burden for this collection of information is estimated to average 6 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: RTI International, 3040 E Cornwallis Rd, Durham NC, 27709 ATTN: Tasseli McKay (919-485-5747). Do not return the completed form to this address.