Demographics Form for Women

Appendix J – Demographic instrument/women – page 2

Appendix J – Supplement to Appendix G

Form Approved

OMB No.

Exp. Date

Brief Demographic Information Form: Women¹

Thank you for your participation in the focus group today. We have just a few questions to ask you. Please fill out this form and let the study staff know if you have any questions. Also, we can go over the form with you if you like.

Information you fill out on this form will not be linked to your name. Please DO NOT write down your name on this form.

Question 1: What is your age? ____ years old

Question 2: How far did you go in school? (Please circle one)

01 Less than 8^th grade

02 8^th grade to 11^th grade

03 Completed 12^th grade or GED

04 Some college

06 College degree like BA or BS

07 Any graduate training

Question 3: Do you consider yourself…(Please circle all that apply)

1. Black or African American

2. White

3. Asian

4. American Indian or Alaska Native

5. Native Hawaiian or Other Pacific

Islander

Do you consider yourself…

6. Hispanic or Latino

yes___ no ____

Question 4: Which of the following best describes your marital or relationship status? (Please circle one)

1. Married and living with your husband

2. Married and not living with husband

3. Legally separated

4. Divorced

5. Widowed

6. Never been married

7. Living with partner (boyfriend, girlfriend)

Question 5: Do you have any children you live with that you are responsible for raising?

1. Yes

2. No

Question 6: Which of the following best describes your monthly household income? (Please circle one)

1. Less than $500

2. $500 - $999

3. $1000 - $1499

4. $1500 - $1999

5. $2000 or more

Question 7: What is your job status?

1. I work full-time (40 hours a week)

2. I work part-time (less than 40 hours a week)

3. I do not have a job – end of the survey

Question 8: If you have a job, what type of job do you have? (e.g., hospital worker, hair dresser, grocery store clerk, child care provider)

______________________________________

This is the end of the survey. Thank you for your participation. Please give this form to the study staff.

1 Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, GA 30333; ATTN: PRA (0920-XXXX).