Form Approved OMB No. 0990-XXXX
Expiration Date XX/XX/XXXX
Background Information for Participant Focus Group
What is your age? _____________
What grade are you in now? _______________
How long have you been participating in the ________________ program? _______ (months)
Are you Hispanic or Latino?
Yes, I am
No, I am not
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 Attention:
PRA Reports Clearance Officer.
OS/OIRM/PRA
200
Independence Ave., S.W., Suite 531-H
Washington D.C. 20201
| File Type | application/msword |
| File Title | Form Approved OMB No |
| Author | GEARS INC |
| Last Modified By | DHHS |
| File Modified | 2010-07-13 |
| File Created | 2010-07-13 |