TIES Contact Updates

OMB Control No: xxx

Expiration Date: xxx

Participant Records Verification

Please verify that the information we have on file for you is accurate.

We have your NAME as: «fname» «mname» «lname»

 _{This is correct}  _{This is not correct (print correct information below)}

Enter Updated Name:

Full Name:

^{First M.I Last}

We have your PRIMARY ADDRESS as: «Participant_StreetAddress» «Participant_Apt»

«Participant_City», «Participant_State» «Participant_Zip»

 _{This is correct}  _{This is not correct (print correct information below)}

Enter Updated Address:

Street Address Apartment/Unit #

_{City State ZIP Code}

We have your MAILING ADDRESS as: «AddressUSE» «APTUSE»

«CITYUSE», «STATEUSE» «ZIPUSE»

 _{This is correct}  _{This is not correct (print correct information below)}

Enter Updated Address:

Street Address Apartment/Unit #

_{City State ZIP Code}

We have your PHONE NUMBER(S) as:

(If not correct, please provide updated information) May we text, including automated texts?

«Participant_phone_C» (cell) Updated Cell Number ___________________________  Yes  No

«Participant_phone_H» (home) Updated Home Number _________________________  Yes  No

«Participant_phone_W» (work) Updated Work number __________________________  Yes  No

If you have any additional phone numbers we may use to contact you, please list them here:

^{Phone number: ( ) Phone number: ( )}

 _cell  _home  _work _other  _cell  _home  _work _other

(We may text you to confirm an appointment, to let you know that we are trying to reach you, or to request that you return your updated contact information form. Some texts may be automated prewritten messages sent by a texting program.)

We have your primary EMAIL Address as: «EMAIL»

 This is the best email to reach me

_{ This is not the best email to reach me (print correct information below)}

_{Enter Best E-mail Address:}

_@

_{□ If you do not have an email or internet access, please check this box.}

What is your preferred method of contact?

 Call cell number  Call home number  Email  Text Message  Other

PLEASE SEE ADDITIONAL INFORMATION ON BACK SIDE

Secondary Contacts: Person 1

Please check below and correct the names, addresses and telephone numbers of the three people you previously provided us who are living outside your household and usually know where to reach you.

If this section is blank, we do not have any alternate contacts for you. Please provide at least one alternate contact, if possible. We will only contact them if we are unable to reach you for the follow-up survey.

The contact information for the BEST PERSON to know how and where to reach you is:

Name: «Cont1_fname» «Cont1_lname» Relationship: «Cont1_RelCoded»

Address: «Cont1_address» «Cont1_city», «Cont1_state» «Cont1_zip»

Primary phone number: «Cont1_cell» Secondary phone number: «Cont1_Phone_Home»«Cont1_Phone_Other»

 This is correct

 This is not correct (print correct information below)

_{Enter updated contact information name, address, relationship and phone numbers.}

Full Name:

Address:

First & Last Relationship

_{Street Address & Apartment/Unit # City State ZIP Code}

Primary Phone: _{( )} Secondary Phone: _{( )}

 cell  home  work other  cell  home  work other

_{Email: @}

Secondary Contacts: Person 2

If this section is blank, we do not have a second alternate contact for you. Please provide that below.

The contact information for the SECOND BEST PERSON to know how and where to reach you is:

Name: «Cont2_fname» «Cont2_lname» Relationship: «Cont2_RelCoded»

Address: «Cont2_address» «Cont2_city», «Cont2_state» «Cont2_zip»

Primary phone number: «Cont2_cell» Secondary phone number: «Cont2_Phone_Home» «Cont2_Phone_Other»

 This is correct

 This is not correct (print correct information below)

_{Enter updated contact information name, address, relationship and phone numbers.}

Full Name:

Address:

First & Last Relationship

_{Street Address & Apartment/Unit # City State ZIP Code}

Primary Phone: _{( )} Secondary Phone: _{( )}

 cell  home  work other  cell  home  work other

_{Email: @}

Secondary Contacts: Person 3

If this section is blank, we do not have a third alternate contact for you. Please provide that below.

The contact information for the THIRD BEST PERSON to know how and where to reach you is:

Name: «Cont3_fname» «Cont3_lname» Relationship: «Cont3_RelCoded»

Address: «Cont3_address» «Cont3_City», «Cont3_State» «Cont3_Zip»

Primary phone number: «Cont3_Phone_Cell» Secondary phone number: «Cont3_Phone_Home» «Cont3_Phone_Work»

 This is correct

 This is not correct (print correct information below)

_{Enter updated contact information name, address, relationship and phone numbers.}

Full Name:

Address:

First & Last Relationship

_{Street Address & Apartment/Unit # City State ZIP Code}

Primary Phone: _{( )} Secondary Phone: _{( )}

 cell  home  work other  cell  home  work other

_{Email: @}

ID: «ABTID3»

«CohortID» Form 1