Discussion group Demographic Survey

E

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