Demographics Form for Community Leaders

Community leader demographic information data collection form – page 2

Appendix K – Supplement to Appendix I

Form Approved

OMB No.

Exp. Date

Brief Demographic Information Form: Community Leaders¹

Thank you for your participation in the focus group today. We have just a few more questions to ask you. Please fill out this form and let the study staff know if you have any questions.

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: Are you male or female? 01 Male

02 Female

Question 3: 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 4: 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 5: How long have you lived in Palm Beach County? _________ years

Question 6: What is your occupation? __________________________________

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).