Form Approved OMB No. 0990-XXXX
Expiration Date XX/XX/XXXX
Background Information for Parent/Legal Guardian’s Focus Group
What is the age of your daughter? _____________
What is your age? ___________
3 |
Ethnicity: Hispanic or Latino Not Hispanic or Latino
|
4. |
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
|
5. I am my daughters’ _____________
Mother
Father
Legal Guardian (Check one below.)
Grandparent
Other Relative (Aunt, uncle, cousin)
Foster Parent
Other
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 Attention:
PRA Reports Clearance Officer.
OS/OIRM/PRA
200
Independence Ave., S.W., Suite 531-H
Washington D.C. 20201
What grade is your daughter now? _____________
How long has your daughter been participating (or participated) in the _______________ program? _______ (months)
Are you currently employed?
Yes
No
If you are employed, please check whether you work fulltime or part-time.
Full-time
Part-time
Are you currently in school?
Yes
No
| File Type | application/msword |
| File Title | Form Approved OMB No |
| Author | GEARS INC |
| Last Modified By | Seleda.Perryman |
| File Modified | 2010-09-27 |
| File Created | 2010-09-27 |