For Payment Only
The following information is only collected for payment purposes. Only the individuals providing payment will see this information. It will not be shared with anyone for any reason other than to provide payment.
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?
* must provide value
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.
* must provide value
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.
* must provide value
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
* must provide value
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.
* must provide value
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
* must provide value
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
* must provide value
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.
* must provide value
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
Youth ID Box 2 - 2nd letter of youth's mother's first name.
* must provide value
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.
* must provide value
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.
* must provide value
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.
* must provide value
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.
Corrected ID (Staff Use ONLY)
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.