Attach K

Attachment K: Participant Data Collection Sheet

DEPARTMENT OF HEALTH & HUMAN SERVICES National Cancer Institute

National Institutes of Health

6130 Executive Blvd

Rockville, MD

OMB# 0925-xxxx

Expiry Date xx/xxxx

Participant 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 current age?

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 or less}

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

 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 either full or part time?

 Yes  No

9. What is your total household income?

 under $20,000  Between $20,000 and $60,000  over $60,000