FABP PR 001 Recruitment Form

U.S. Election Assistance Commission
Free or Reduced Return Postage Study
FOCUS GROUP - RECRUITMENT FORM

1.

Are you a US Citizen?
1.
2.

2.

Gender
1.
2.

3.

Male
Female

Can you please tell me which of the following categories your age falls into?
1.
2.
3.
4.
5.
6.

4.

Yes
No

18-25
26-35
36-45
46-55
56-65
66+

What is the highest level of education you have attained?
1.
2.
3.
4.

High school or less
Some college or vocational education
Bachelor’s degree
Post-graduate degree

Q5 and Q6 for Recruitment of people with disabilities ONLY
5.

Do you have any type of disability which limits you physically?
1.
2.

6.

Yes
No

[If Yes to Q5] What kind of disability do you have?
1.
2.
3.
4.

Hearing loss
Impaired vision or loss of vision
Limitation in physical mobility
Mental disability

7.

8.

How interested are you in politics and government?
1.
2.
3.

Very Interested
Somewhat Interested
Somewhat Disinterested

4.

Very Disinterested

Can you tell me if you voted in the 2006 mid-term elections?
1.
2.
3.

9.

[If Yes to Q8] Which method did you use to vote in the mid-term election?
1.
2.
3.

10.

At the polling station
Through absentee ballot
Other

[If did not vote through absentee ballot for 2006 mid-term or 2004 presidential election]
Have you ever voted through absentee ballots for any Presidential or Congressional
election?
1.
2.

13.

Yes
No
Do not remember

[If Yes to Q10] Which method did you use to vote in the presidential election?
1.
2.
3.

12.

At the polling station
Through absentee ballot
Other

Can you tell me if you voted in the 2004 presidential election?
1.
2.
3.

11.

Yes
No
Do not remember

Yes
No

What is your employment status?
1.
2.
3.
4.
5.
6.

Employed full-time
Employed part-time
Unemployed
Retired
Student
Homemaker

14.

Can you tell me which of the following categories does your household’s total income fall into?
1.
2.
3.
4.
5.

Under $20,000
$20,001 to $25,000
$25,001 to $35,000
$35,001 to $45,000
Greater than $45,000

*This information collection is required for the EAC to meet its statutory requirements under the
Help America Vote Act (HAVA) of 2002 (42 U.S.C. 15301). Respondent’s obligation to reply to
this information collection is voluntary; respondents include the 50 States, and the District of
Columbia. This information will be made publicly available on the EAC website at www.eac.gov.
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a
person is not required to respond to, a collection of information unless it displays a valid OMB
control number. The valid OMB control number for this information collection is OMB Control
No. pending (expires: to be determined). The time required to complete this information
collection is estimated to average 1.25 hours per response. Comments regarding this burden
estimate should be sent to the Program Manager – 2007 Study of the Feasibility and Advisability
of Establishing a Program of Free Return Postage for Absentee Ballots, U.S. Election Assistance
Commission, 1225 New York Ave, NW, Suite 1100, Washington, DC 20005.