Program Partners -Focus Group

Girls at Greater Risk for Juvenile Delinquency and HIV Prevention Program

Respondent-Program Partners Focus Group Background Form 9_14_10

Program Partners -Focus Group

OMB: 0990-0360

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Form Approved OMB No. 0990-XXXX

Expiration Date XX/XX/XXXX



Background Information for Partners Focus Group

  1. What organization do you represent? _____________



  1. How long has your organization been providing services? ______________

    1. How long has your organization been providing services for girls?________



  1. How long have you been a staff member of your organization? _______ (years)



  1. What is your position in the organization? _______________



  1. Were you involved in providing direct services to participants in the __________________ program? Yes ____ No____



    1. If yes, what service(s) did you provide? _____________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

    1. How long did you provide services, if any, to the ___________________ program?

______________________________



  1. What is your age? ___________







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 5 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.














  1. Are you Hispanic or Latino?

Yes, I am

No, I am not


  1. What is the racial category you most closely identify?

American Indian or Alaska Native

Asian or Pacific Islander

Black or African American

White

Other (specify): ___________





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File Typeapplication/msword
AuthorGEARS INC
Last Modified ByGEARS INC
File Modified2010-09-14
File Created2010-09-14

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