Program Participants (girls and female adolecents)

Girls at Greater Risk for Juvenile Delinquency and HIV Prevention Program

0990-GirlsBackground Form Participants final (3)

Program Participants (girls and female adolecents)

OMB: 0990-0360

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Form Approved OMB No. 0990-XXXX

Expiration Date XX/XX/XXXX



Background Information for Participant Focus Group



  1. What is your age? _____________



  1. What grade are you in now? _______________



  1. How long have you been participating in the ________________ program? _______ (months)


  1. Are you Hispanic or Latino?

 Yes, I am

 No, I am not

  1. What else do you call yourself? (Select all that apply)

 American Indian or Alaska Native

 Asian or Pacific Islander

 Black or African American

 White

 Other (specify): ___________



According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-XXXX. The time required to complete this information collection is estimated to average 3 minutes per response including the time to review instructions, search existing data resources, the gather data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:



U.S. Department of Health & Human Services
OS/OIRM/PRA
200 Independence Ave., S.W., Suite 531-H
Washington D.C. 20201

Attention: PRA Reports Clearance Officer.



File Typeapplication/msword
File TitleForm Approved OMB No
AuthorGEARS INC
Last Modified ByDHHS
File Modified2010-07-13
File Created2010-07-13

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