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a3 <br />Appendix 2: Telephone Survey Form <br />Mill Creek Road Area Survey Survey Status: <br />Completed- <br />Orange County Health Department, Hillsborough, NC Attempted, no contact, try again- <br />October 2005 Call back for (person) a[ (date/time) <br />Lltert~iew Lrfortnntion <br />1. DATE 2. PROP. TMBL <br />MM/DD/YYYY <br />2A. PROPERTY ADDRESS <br />LASTNAME, FIRSTNAME <br />AUTO-FILL <br />2B. TELEPHONE <br />AUTO-FILL <br />3. PROPERTY OWNER <br />4. INTERVIEWER <br />AUTO-FILL <br />OWNER 2 <br />FIRST NAME LAST NAME <br />5. INTERVIEW TIME <br />FIRST ATTEMPT SECOND <br />ATTEMPT <br />Dnta Collectiotr <br />6. DO YOU LIVE AT THIS ADDRESS? ^ YES ^ NO <br />6a. IP' NO, PLEASE PROVIDE THE NAME AND Name: <br />TELEPHONE NUMBER OF THE PERSON WHO LIVES Telephone #: <br />AT THIS ADDRESS <br />7. WHAT IS YOUR FH25T NAME? <br />8. WHAT IS YOUR LAST NAME? <br />9. ADDRESS <br />HOUSE NUMBER AND STREET NAME <br />CITY STATE ZIP <br />Page 21 of 47 <br />