Form #2 Form #2 Self-administered Questionnaire

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

Date

//

Participant ID

Attachment G
PARTICIPANT DEMOGRAPHIC INFORMATION
For optimum accuracy, please print carefully in capital letters and avoid contact with the
edges of the box. Use the following as examples:
A

B

C

D

E

F

G

H

N

O

P

Q

R

S

T

0

1

2

3

4

5

6

I

K

L

M

U V

W X

Y

Z

7

9

8

J

For choice questions, please mark only one box: 

1. Marital Status

 Single, Never Married
 Married
 Widowed
 Separated
 Divorced
 Common-Law (Living together but not legally married)
 Living with a Significant Other or Partner
Public reporting burden for this collection of information is estimated to average 6 minutes per
response, the estimated time required to complete the survey. 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. Form Approved: OMB Number 0935-XXXX Exp. Date
xx/xx/20xx. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden, to: AHRQ Reports
Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540
Gaither Road, Room # 5036, Rockville, MD 20850.

Demographic Information

Participant ID

2. Education

 Less than High School Diploma or Equivalent
 High School Diploma or Equivalent
 Trade or Technical School
 Some College
 Bachelor’s Degree
 Advanced Degree
3. Employment

 Employed Full Time
 Employed Part Time
 A Homemaker
 Unemployed
 Disabled
 In School
 Retired
 Something Else? (Specify)
4. Annual Household Income

 Less than $10,000

 $40,000-$49,999

 $10,000 - $14,999

 $50,000-$74,999

 $15,000 - $19,999

 $75,000-$99,999

 $20,000 - $24,999

 $100,000-$124,999

 $25,000 - $29,999

 $125,000 or Up

 $30,000 - $39,999

 Refuse to Answer

Demographic Information

Participant ID

5. Language

 English
 Spanish
 Spanish and English
 Some other language (Specify)
6. Ethnicity Information
Demographic
1. Are you Hispanic or Latino/Latina?

 No
 Yes
2. What is your race? Please select one or more.

 American Indian or Alaska Native
 Asian
 Native Hawaiian or other Pacific Islander
 Black or African American
 White

8. Gender

 Male
 Female

Participant ID

Demographic Information

Participant ID

7. Insurance

 No insurance
 Private Insurance - HMO
 Private Insurance - PPO
 Private Insurance - Don’t know
 Medicaid (Gold Card)
 Medicare
 VA (CHAMPS)
 Other (Specify)

Please tell us anything that you were not able to talk about with the group.

Physician Demographics
1) I graduated from medical school in ________
year

2) I finished my most recent post-graduate training (residency or fellowship) in ________
year

3) Gender: Male ______

Female ______

4) Age: ______

5) Specialty:
_______
_______
_______
_______
_______

Family Practice
Pediatrics
General Internal Medicine
Other Internal Medicine Subspecialty __________________
Other specialty __________________

Pharmacist Demographics
1) I graduated from pharmacist’s school in __________
year

2) I have worked as a pharmacist for ______ years and ______ months
3) Gender:

Male_______ Female_______

4) Age: ________