If we cannot reach you directly, are there other people we can call who can get in touch with you and let you know we would like to speak with you? When we contact them, we will not disclose the name of the program or any activities you are involved in here. Instead we will just leave a name and phone number for you to call.
Is there any place you go regularly to hang out or to meet with friends?
I hereby authorize a representative of NSTC to contact the individuals named above in order to obtain my updated contact information, including new addresses, phone numbers or email contacts, or to leave a message with them asking me to contact a representative of NSTC via phone, text or email.
Date of Expiration
The date, event, or condition upon which this consent will expire without my expressed revocation shall be
Which is of duration no longer than that reasonably necessary to effectuate the purpose for which this consent is given.
I understand that I may revoke at any time except to the extent that action has been taken in reliance thereon.
I further understand that such disclosure shall be limited to information necessary in the light of the need or purpose for the disclosure.
I further understand that Title 21 U.S.C 1175 and 42 C.F.R., Part 2 require that information released pursuant to this consent remains subject to the restriction that it not be further disclosed or used for any purpose other than as stated herein without my specific written consent, or as otherwise permitted by such Federal law and regulations.
