Youth 1st, 2nd, 3rd and 4th (Male, Rural Smokeless) follow up questionnaire

Attachment 33_R: Panel Maintenance Update Form - 18

Form Approved

OMB No. 0910-0753

Exp. Date 09/30/2019

RIHSC No. 15-101CTP

FDA Health and Media Study

Contact Information Update Form

CaseID

Please complete Parts 1 and 2 below and mail this form back to us in the postage-paid envelope provided.

PART 1. CURRENT CONTACT INFORMATION ON RECORD

Please review the current contact information we have for you below, cross through anything that is incorrect, and write your new information in the space provided. If all of the information is correct, please check the “Contact Information Correct” box and complete PART 2. If you provided a cellphone number, the field interviewer may use text messaging to reach you. Please indicate if you do not wish to receive text messages.

CURRENT CONTACT INFORMATION: UPDATED CONTACT INFORMATION:

Participant Name

Address1 Address2

City, State Zip

Telephone

Email Address

CONTACT INFORMATION CORRECT

I DO NOT WISH TO RECEIVE TEXT MESSAGES

PART 2. CONTACT INFORMATION IF YOU PLAN TO MOVE

Do you plan to move in the next 6 months? Yes No

If you plan to move in the next 6 months and know your new address and telephone number, please enter it in the space below.

If you plan to move and do not know your new address and telephone number, please provide a phone number we can use to reach you.

Date you plan to move: ____________________________________________

Address: ________________________________________________________

City: _______________________________ State _________ Zip___________

Phone: (____) _________________ (circle one): Home Work Cell phone

This information, including your cellphone number, will be kept private to the extent allowable by law. Only research team members who need to contact you will have access to your information. All field interviewers who contact you by cellphone or text message will be required to delete your information from their cellphones within 24 hours of the end of each wave of data collection.

Thank you for your assistance!

OMB No: 0910-0753 Expiration Date: 09/30/2019

Paperwork Reduction Act Statement: The public reporting burden for this collection of information has been estimated to average 5 minutes per response. Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing burden to PRAStaff@fda.hhs.gov.

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