2 Screen and Roster

OMB#: 0925-XXXX

Exp. XX/XXXX

Public reporting burden for this collection of information is estimated to average 10 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-XXXX). Do not return the completed form to this address.

H

OMB#: 0925-XXXX

Exp. XX/XXXX

CHS/SOL Household Screening

HOUSEHOLD ID NUMBER:

FORM CODE: HSR VERSION: A 7/30/07

Contact Occasion

SEQ #

Administrative Information COMPLETION dATE: // 0b. Staff ID:

mm dd yyyy

Instructions: Mark a check in the appropriate box for the response. Unless instructed, mark ONLY one response. Complete only one form per household. Record the selection probability (p) and the cut-point (c) for the household from the selection worksheet provided by the Coordinating Center used in question 3a.

1. Does anyone live in this household that is of Hispanic/Latino origin? No 0  STOP, read closing script

Yes 1

2. Is at least one person of Hispanic/Latino origin living in the household between the ages of 18 – 74? No 0  STOP, read closing script

Yes 1

3. Are ALL Hispanics/Latinos living in the household that are between the ages of 18-74, also between the ages of 45-74?

No 0

Yes 1  CONTINUE to item 4 below

Selection, p = 0.____

Cut-point, c = 0.____

3a. Is Selection p less than Cut point c?  Yes 1 CONTINUE to item 4 below

Otherwise, household not eligible  No 0 STOP, read closing script

4. Please list the names of all individuals aged 18 – 74 who are of Hispanic/Latino origin and who consider this their permanent residence (include yourself). We will need first name and last name, gender of the person, age, and relationship to you.

Gender Relationship

First Name Last Name M/F Age to Respondent

A. 01*

B. *

C. *

D. *

E. *

F. *

G. *

H. *

*Use the following codes for relationship to respondent:
Respondent	01	Daughter	03	Mother	05	Sibling	07	Niece	09	Son-in-Law	11	Mother-in-Law	13	Other relative	15
Spouse	02	Son	04	Father	06	Cousin	08	Nephew	10	Daughter-in-Law	12	Father-in-Law	14	Other	16

First Name Last Name M/F Age to Respondent

I. *

J. *

K. *

L. *

M. *

N. *

O. *

P. *

*Use the following codes for relationship to respondent:
Respondent	01	Daughter	03	Mother	05	Sibling	07	Niece	09	Son-in-Law	11	Mother-in-Law	13	Other relative	15
Spouse	02	Son	04	Father	06	Cousin	08	Nephew	10	Daughter-in-Law	12	Father-in-Law	14	Other	16

Household Screening (HSR) Page 2 of 2