Update Contact Hardcopy Form

Form Approved

OMB No. 0923-XXXX

Exp. Date xx/xx/201x xx/xx/20xxExDaxx/xx/20xx

Exp. Date xx/xx/20xx

Attachment 12.

Pease Study

ATSDR estimates the average public reporting burden for this collection of information as 5 minute per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0923-xxxx).

Update Contact Information Hardcopy Form

Adult Study ID No. |_________________| Parent Study ID No. |_________________| Child Study ID No. |_________________|		Comments
Name:
Street Address:
City:
State:
Zip Code:
Work Phone:
Home Phone
Cell Phone:
Email:

SCRIPT: We may want to contact you again to ask some clarifying questions. Keeping in mind that people move, we would like to get a little more information to help us locate [you/and your child] in the future. In case you move to another residence, will you give us the names and contact information of three people who live outside of your household who would always know how to find you?

___Yes

___No

Fill out the table below. Circle appropriate response and ask the respondent to specify as directed. Complete the information for the first person completely before asking about the next person.

	Person 1	Person 2	Person 3
What is the first and last name of the first/second/third person?	First name: Last name:	First name: Last name:	First name: Last name:
What is the address of the first/second/third person?	Street no. and name ___________________ City State Zip code	Street no. and name ___________________ City State Zip code	Street no. and name ___________________ City State Zip code
What is the phone number, including area code of the first/second/third person?	(_ _ _)_ _ _ - _ _ _ _	(_ _ _)_ _ _ - _ _ _ _	(_ _ _)_ _ _ - _ _ _ _
What is the email address of the first/second/third person?
What is the first/second/ third person’s relationship to you?	Parent Child Sibling Other relative (Please specify) _________________ Other (Please specify) _________________	Parent Child Sibling Other relative (Please specify) _________________ Other (Please specify) _________________	Parent Child Sibling Other relative (Please specify) _________________ Other (Please specify) _________________