1 Pre-Focus Group Form

OMB control number 0925-0634

Burden Disclosure Statement

Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0634). Do not return the completed form to this address.

Pre-Focus Group Questionnaire

1. Are you a formal or informal caregiver for an older family member or friend?

• Formal

• Informal

2. What is your relationship with this person?

   • Parent

   • Grandparent

   • Sibling

   • Aunt/Uncle

   • Cousin

   • Other ______________________________

3. Does this person live with you?

   • Yes

   • No

4. Which best describes you:

   • I have a home computer

   • I do not have a home computer, but I have access to another computer (such as at a library); I use the computer at:___________________________

   • I do not have access to a computer

5. Which best describes your internet access:

   • Dial-up internet

   • High speed internet

   • No internet access (at home or outside of home)

6. How do you get your health information? (Please check all that apply and, where indicated, please fill in specific details.)

• Television; Program Name:__________________________________________

• Newspaper; Name: ________________________________________________

• Magazine; Name: _________________________________________________

• Newsletter; Name: _________________________________________________

• Online; Name of Website: ___________________________________________

• Radio; Channel:____________________________________________________

• Books

• Doctor

• Family member

• Friend

• Other; Please explain: ______________________________________________

7. Before being part of this discussion group, had you heard of the National Institute on Aging (NIA) and/or the National Institutes of Health (NIH)?

• Yes, both NIA and NIH

• Yes, just NIA

• Yes, just NIH

• No

8. What is your ethnicity?

   • Hispanic or Latino

   • Not Hispanic or Latino

9. What is your race? (You can choose more than one)

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

10. What is your age?

11. What is the age of the family member/person you find health and aging information for?