Page 163 - QAP Manual 2020
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NCI™ ADULT IN-PERSON SURVEY (IPS) 2020-21
B. Person to be surveyed
Individual’s Name
Gender: □1. Male □ 2. Female □ 3. Other
Age
Phone
Email
Street Address
City State Zip
C. Legal guardian/conservator information, if applicable
Guardian/Conservator’s Name
Relationship to Individual
Phone
Email
Street Address
City State Zip
D. Approval requirements and procedures
ADVICE TO STATES. Each state will follow its own specific requirements for getting the individual’s
consent or agreement to participate.
ADVICE TO SURVEYORS. At a minimum, you need to obtain verbal agreement from the individual (or
his/her legal guardian/conservator, if applicable) before the face-to-face survey takes place.
Note. The agreement/approval question at the beginning of Section I must be answered.
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