Focus Group -Program Participants' (girl and female adolescents)

Girls at Greater Risk for Juvenile Delinquency and HIV Prevention Program

Respondent-Program Participants' Focus Group Background Form 9_16_10

Focus Group -Program Participants' (girl and female adolescents)

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. Ethnicity:

 Hispanic or Latino

 Not Hispanic or Latino


  1. Race: (You can choose more than one category.)

 American Indian or Alaska Native

 Asian

 Black or African American

 Native Hawaiian or Other Pacific Islander

 White




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 XXXX-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
AuthorGEARS INC
Last Modified ByEdward
File Modified2010-09-16
File Created2010-09-16

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