Discussion group Demographic Survey

Evaluation of Office on Women's Health Publications

EvaluationofWomensHealthBreastfeeding FG Demographic Survey - OWH Publications 7.12.07

Discussion group Demographic Survey

OMB: 0990-0319

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Form Approved

OMB No. 0990-XXXX

Exp. 07-XX-2008

asy Guide to Breastfeeding Discussion Groups

Demographic Survey


How old are you?

18 - 24 yrs

25 - 29 yrs

30 - 39 yrs

40 – 49 yrs

50 – 59 yrs

60+ yrs

What is the highest level of education that you have completed?

Part of high school

High School Graduate/GED

Part of college/university

College/University Graduate

Graduate School

What is your race? Check all that apply.

Black/African American

White/Caucasian

Hispanic or Latino

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Asian


How long have you lived in your current home? ____ Months ____Years

In what city and state do you live?

______________________ ___ ___

city state

In what type of area do you live?

Rural

Suburban

Urban

What type of job do you have?

One full-time job (40+ hours/week)

One part-time job (10-20 hours/week)

Both a full-time and a part-time job (50-70 hours/week)

I do not work

What is your line of work? _________________________________________________

Do you have health insurance?

Yes No

What is the highest level you completed in school?

No schooling completed

8th grade or less

Some high school, no diploma

High school graduate or GED

Some college, no degree

Associate or Bachelor’s (i.e. college)

degree

Graduate or professional degree

According to the Paperwork Reduction Act of 1995, no persons are 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 0990- . The time required to complete this information collection is estimated to average ( hours)(minutes) per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/ocio/PRA, 200 Independence Ave., S.W., Suite 531-H, Washington D.C. 20201, Attention: PRA Reports Clearance Officer. Alice Bettencourt

File Typeapplication/msword
File TitleHow old are you
AuthorMichele D. Sadler
File Modified2007-07-12
File Created2006-06-22

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