Head Start Study Interest Form: Contact Information | Study Interest Form

Thank you for your interest in this study. The following questions will let us know if you are eligible to join. It should take about 5 minutes to complete. Your answers will be kept private. Try to be as accurate as possible in your responses. Only the research team members will have access to your answers.

Please note that submitting this interest form does not guarantee that you will be eligible to join the study. We will review your responses and contact you soon to let you know if you are eligible and provide you with next steps. If you prefer to talk to someone before completing this form or need help completing this form, please call us at 434-962-5870.

Contact Information

This first set of questions allows us to contact you about your eligibility for the study and next steps.

What is your first name?

What is your last name?

As part of the study we will use your email and cell phone number to contact you about enrollment, complete study activities, and remind you of study tasks. We do not share your contact information with anyone outside of the study.

For purposes of joining the study, please provide your email address below:

If you do not have an email and need help creating one, please either ask your Head Start administrator for help, or call the study coordinator at 434-962-5870.

And also your personal cell phone number.

Is it okay to leave a text and/or voice message about this study at this number?

Both text and voice messages are okay

Only leave text messages

Only leave voice messages

You may not leave a text or voice message

What is another phone number that we can use to contact you if we are unable to reach you on your personal cell phone? Please provide that number.

Leave blank if there is no alternate number.

What is your zip code?

What time zone do you live in?

What are the best days and/or times to reach you?