QDRL-OMB Attachment E

Attachment E

Respondent Data Collection Sheet

DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service

Centers for Disease Control and Prevention

National Center for Health Statistics

3311 Toledo Road

Hyattsville, Maryland 20782

OMB# 0920-0222; Approval expires 02/28/2010

Note to Reviewers: We are currently in the process of revising this form. Once the form has been revised, and we have received ERB approval for the revisions, we will forward an updated copy.

Respondent Data Collection Sheet

For our records we would appreciate it if you would take a minute to fill out this form.

1. How did you hear about us?

Newspaper Ad: Flyer: Word of Mouth:

 Gazette  Giant  Friend

 Sentinel  Safeway  Co-worker

 Washington Post/Express  Other  We called you to come back

2. Are you male or female?

 Male  Female

3. What is your age?

_________

4. What is your marital status?

 Married  Divorced  Widowed  Separated  Never been married

5. Are you Hispanic or Latino?

 Yes  No

6. What is your race? Mark one or more races to indicate what you consider yourself to be.

 American Indian or Alaska Native

 Asian

 Black or African American

 Native Hawaiian or other Pacific Islander

 White

7. What is the highest grade of school you have completed?

9^th

10^th

11^th

12^th no diploma

 High School Graduate - High School Diploma or the equivalent (for example: GED)

 Some college but no degree

 Associate Degree in college - Occupational/vocational program

 Associate Degree in college - Academic program

 Bachelor’s degree (For example: BA, AB, BS)

 Master’s degree (For example: MA, MS, MEng, MEd, MSW, MBA)

 Professional or Doctorate (for example: MD, PhD, DVM, JD)

8. Are you currently employed?

 Yes  No

9. What is your total household income?

 20K or less  30K or less  over 30K