Home Appliance Owner: Exit Questionnaire

Form Approved

OMB No. 0920-XXXX

Expiration Date XX/XX/20XX

ATTACHMENT 14:

HOME APPLIANCE OWNERS EXIT QUESTIONNAIRE

Public reporting burden of 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 CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

Focus Group Information Sheet

Name ____________________________________

Household Questions

1. When buying home improvement items, where do you most often shop?

____________________________________

2. If you have installed a smoke alarm in your home, please tell us how you obtained the smoke alarm?

____________________________________

3. Please list any products that you have bought in order to improve safety and prevent injury in your home?

___________________________________

___________________________________

___________________________________

4. Please list any household appliances that you have bought for your home (e.g. water heater, stove, washer and dryer), after the date you purchased your home.

___________________________________

___________________________________

___________________________________

5. Do you currently pay for a service contract for the maintenance and service of any household appliances or systems?

Yes

No

If YES, please list the appliances that are covered under your plan(s)?
__________________________________________________________

Media Usage

6. Which sources do you prefer when getting information about things or events in your community? (check all that apply)

Newspaper

Radio

Television
Internet

Community Newsletters and other mailings

Other ____________________________

7. What is your preference of sources for receiving information about your health and personal safety? (check only one box)

Newspaper

Radio

Television
Internet

Community Newsletters and other mailings

Other ____________________________

Demographics

8. How old are you?

___________________________________

9. How many people currently live in your home?

___________________________________

10. What is the highest grade or year of school you finished?

Never attended school or only attended kindergarten
Grades 1 through 8 (elementary)
Grades 9 through 11 (some high school)
Grade 12 or GED (high school graduate)
College 1 year to 3 years (some college or technical school)
College 4 years (college graduate)

Graduate school or more

11. What is your annual household income from all sources?

No income

Less than $10,000
$10,000-$29,999

$30,000-$49,999

$50,000-$69,999

$70,000-$89,999

$90,000-$119,999

$120,000 or more

END

(Reading level on the Flesch-Kincaid scale: 7.1)