Various Demographic Area Pretesting Activities

Date Participant Number______

Appendix B: Introductory Worksheet

Thank you for agreeing to participate today! You should have been given a participant number when you signed in. Please write it in the space at the top of this form. You will be asked to use this number a few times throughout our discussion today, so please remember it. Before we begin the discussion, take a few minutes and fill out this short form.

First, in your own words, please explain what you think a “government agency record” is:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Now, what do you think a government statistical agency is? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Thanks! Now, consider the following 12 entities that hold some of your personal information, and answer the following questions next to each entity:

1. What information does this entity have about you?

2. How did this get your information>

3. How long does this entity keep this information?

4. Is this entity legally allowed to share your information?

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Lastly, please answer the following questions about yourself:

1. What is your age?

2. What race do you consider yourself to be? Mark all that apply

a. American Indian or Alaska Native b. Asian

c. Black or African American d. White

e. Native Hawaiian or Other Pacific Islander

3. Are you of Hispanic, Latino, or Spanish Origin?

a. Yes b. No

4. What is the highest level of education you’ve completed?

a. Graduate Degree b. College Degree

c. Some College d. High School Degree

e. Less than High School