Form 1 Community Residents Form

OMB No.: XXXX – XXXX

Expiration Date: XX/XXXX

Community Event Survey

Today’s Date: ____/____/____ Name of today’s community event:________________________
Gender: ______ Female ______ Male Age: _____________
Ethnicity:  Hispanic or Latino  Not Hispanic or Latino 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
1.	How did you learn about today’s event?  TV, radio or print ad (includes billboards, flyers, etc.)  ___________________________________Program Staff  My teacher/principal/someone at school told me  Word of mouth (My friend told me)  I saw/heard the event and came over to check it out  Other ___________________________________(please specify)
2.	How much new information did you learn today?  A lot! All of the information they shared was new to me  Some. I didn’t know most of the information they shared today  A little. I already knew most of the information they shared  None. I already knew everything they told me
3.	How much will the information you learned today change how you think and act in the future?  A lot  Some  A little  Not at all
4.	What did you think about today’s event overall?  I liked it a lot  Some  It was O.K.  I did not like it at all
5.	Do you think you will come to another community event like this one in the future?  Yes, I will come to another event  I probably will come to another event  I probably will not come to another event  No, I will never come to another event

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 5 minutes per respondent, including the time to review instructions, search existing data resources, gather the 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