Contact Information Form

Contact Information Form
10/20/2000
ID NUMBER:
0
CONTACT YEAR:
LAST NAME:
FORM CODE: CON
VERSION A
1
INITIALS:
On the paper form, record an equal sign (=) in the first response box for a missing item. For data entry, set a permanently
missing flag for any item with an equal sign in the first box. Do not enter the equal sign.
A.
PARTICIPANT INFORMATION
“Now I would like to obtain some information which will help us contact you later.”
1.
Please tell me what title you use before your name,
for example: Mr., Mrs., Ms., Doctor, Reverend,
or something else? ……………………………………………………
2.
Would you please spell your last name for me:
3.
Please spell your first name for me: …………………..
4.
Please spell your middle name for me: ………………..
………………………..
Would you tell me your complete mailing address:
5a.
5b.
5c.
6.
5d.
City: ……..
5e.
State: ……
5f.
What is your home telephone number
starting with your area code? …………………………..
IF NO HOME TELEPHONE NUMBER GO
TO ITEM 8
Zip Code:
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7a.
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9.
What is the best time for us to contact you at home? …
What is your work telephone number
starting with your area code? …………………………..
What is your Pager number
starting with your area code? …………………………..
10. What is your Cell phone number
starting with your area code? …………………………..
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11. What is your Email address?
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“Since we will be contacting you for several years, we would like to obtain some information now which will help
us locate you in the future. Remember that all information is confidential and that anyone we might contact will
be told only that we are trying to locate you for a health study. Please give me the contact information of three
close friends or relatives who you are likely to keep in touch with but who do not live with you, and who are not
planning to move anytime soon.”
B.
FIRST CONTACT PERSON
Specify name and relationship of f i r s t contact person:
12a. Last Name: …………………………………….
13.
12b.
First Name: ……………………………
12c.
Relationship?
F i r s t Contact Person home phone number: …………
IF NO HOME TELEPHONE NUMBER GO
TO ITEM 15
14a. What is the best time for us to contact him/her
at home? ……………………………………………………
15.
Work phone number: …………………………………….
16.
Pager number: …………………………………………….
17.
Cell phone: …………………………………………………
18.
Email address:
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C.
SECOND CONTACT PERSON
Specify name and relationship of s e c o n d contact person:
19a. Last Name: …………………………………….
20.
19b.
First Name: ……………………………
19c.
Relationship?
S e c o n d Contact Person home phone number: ……..
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IF NO HOME TELEPHONE NUMBER GO
TO ITEM 22
21a. What is the best time for us to contact him/her
at home? ……………………………………………………
22.
Work phone number: …………………………………….
23.
Pager number: …………………………………………….
24.
Cell phone: …………………………………………………
25.
Email address:
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D.
THIRD CONTACT PERSON
Specify name and relationship of t h i r d contact person:
26a. Last Name: …………………………………….
27.
26b.
First Name: ……………………………
26c.
Relationship?
T h i r d Contact Person home phone number: ………..
IF NO HOME TELEPHONE NUMBER GO
TO ITEM 29
28a. What is the best time for us to contact him/her
at home? ……………………………………………………
29.
Work phone number: …………………………………….
30.
Pager number: …………………………………………….
31.
Cell phone: …………………………………………………
32.
Email address:
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E.
PHYSICIAN CONTACT INFORMATION
“We would also like the name, address, and telephone number of your primary health care provider. Can you give
me this information now, or would you prefer to bring it with you to the clinic visit?” [IF BRING TO CLINIC,
GIVE PARTICIPANT THE R E Q U E S T F O R P H Y S I C I A N C O N T A C T I N F O R M A T I O N F O R M .]
33.
[D
D O N O T A S K ; RECORD APPROPRIATE RESPONSE.]
Complete physician contact information obtained
O
Participant will bring information to clinic
C
Participant to provide at 24-hour pick-up
P
Refusal or no health care provider
R
Go to Item 38
Health Care Provider’s Name:
34a. Last name: …………………………………………………..
34b. First name: …………………………………………..
35a. Is your primary health care provider a physician,
nurse practitioner, or some other provider? …………….
35b. Other (specify):
Physician
P
Nurse practitioner
N
Other
O
Go to Item 36a
Street address:
36a.
36b.
36c.
36d.
City: ……..
36e.
State: ……
36f.
37. Telephone number: …………………………………………
CON/Version A 10/20/2000
Zip Code:
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F.
ADMINISTRATIVE INFORMATION
38.
Date of data collection: ………………….
39.
Method of data collection: …………………………………………….. .. Computer
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Paper Form
40.
Code number of person completing this form: ………………………………
41.
Date Home Induction Interview
completed: …………………………………
42a. Time Home Induction Interview
completed: …………………………………
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