For Payment Only
Interview date:
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Today M-D-Y
Sanna Schneeberger Steven James Courtney Moore Janee Henderson Jomella Watson-Thompson Other Monica Mendez Sara Obermeier
If you selected other, please specify:
Are you collecting information to issue a new Clincard or for a Replacement Clincard?
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New Clincard Issued
Replacement Clincard Issued
Referral - Were you referred to us by someone?
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Yes
No
Referral Name - What is the first and last name of the person that referred you?
* must provide value
Referral Phone Number- What is the phone number of the person that referred you?
* must provide value
Referral Email - What is the email address of the person that referred you?
Parent - What is your first, middle and last name?
Parent - What is your Social Security number?
Parent - What is your date of birth?
Parent - What is your home phone number?
Parent - What is your cell phone number?
Parent - What is your email?
Parent - Do you prefer to be contacted by email or text?
Email
Text
Parent - What is your street address (e.g., 123 Main St).
* must provide value
Parent - What city do you live in?
* must provide value
Parent - What is your zip code?
* must provide value
Below is a system for making a unique ID for your survey. In no way does this allow anyone to trace your responses back to you.
Parent ID Box 1 - 3rd letter of your first name.
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
Parent ID Box 2 - 2nd letter of your mother's first name.
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
If you do not know your mother's first name, please choose "X"
Parent ID Box 3 - Your middle initial
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
If you do not have a middle name, please choose "X"
Parent ID Box 4 - 2nd letter of your last name.
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
Parent ID Box 5 - 1st letter of your birth month
A D F J M N O S X
If you do not know your birth month, please choose "X"
Parent Study ID: ______ ______ ______ ______ ______
Copy Study ID here.
Youth Full Name
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First, middle, last.
Youth - What is your Date of Birth?
* must provide value
Youth - What is your cell phone number?
* must provide value
Youth - What is your email?
* must provide value
Create the unique ID for the youth, below.
Youth ID Box 1 - 3rd letter of youth's first name.
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
Please spell your mother's first name
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
If youth does not know mother's first name, please select the letter "X"
Youth ID Box 3 - Youth's middle initial.
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
If youth does not have a middle name, please select the letter "X".
Youth ID Box 4 - 2nd letter of youth's last name.
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
Youth ID Box 5 - 1st letter of youth's birth month.
A D F J M N O S X
If youth does not know birth month, please select the letter "X".
Youth Study ID: ______ ______ ______ ______ ______
Copy Youth ID here.
Youth - What is your Social Security number?
Youth - Do you use the same contact information as your parents (address, phone, email)?
Yes
No
Youth - What is your home phone number?
Youth - What is your cell phone number?
* must provide value
Youth - What is your email?
* must provide value
Youth - Do you prefer to be contacted by email or text?
Email
Text
Youth - What is your street address (e.g., 123 Main St).
* must provide value
Youth - What city do you live in?
* must provide value
Youth - What is your zip code?
* must provide value
Parent - Card Token Number: Please indicate the token number.
Parent - Please indicate the expiration date.
Parent - Signature: Please provide your signature that indicates a debit card was provided to you.
Youth - Card Token Number: Please indicate the token number.
Youth - Please indicate the expiration date.
Youth - Signature: Please provide your signature that indicates a debit card was provided to you.
Thank you. That's the end of our interview.
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