LOI2-QUEX-14 ACCULTURATION QUESTIONNAIRE ATTACHMENT C.4.8
OMB#: 0925-0593
OMB Expiration Date: 07/31/13
Acculturation and Food Programs Instrument
(Pregnant Women)
Were you born in the United States?
Yes (skip to question 2) 1
No 2
Refused 9--97
Don’t know 9--98
In what country were you born?
Specify: _____________________________________________
(Source: http://www.state.gov/s/inr/rls/4250.htm#note2)
Refused 9--97
Don’t know 9—98
About how long have you lived in the United States?
|___|___|
YEARS
Refused 9--97
Don’t know 9—98
Was your mother born in the United States?
Yes (skip to question 3) 1
No 2
Refused 9--97
Don’t know 9--98
In what country was your mother born?
Specify: _____________________________________________
(Source: http://www.state.gov/s/inr/rls/4250.htm#note2)
Refused 9--97
Don’t know 9—98
Was your father born in the United States?
Yes (skip to question 4) 1
No 2
Refused 9--97
Don’t know 9--98
In what country was your father born?
Specify: _____________________________________________
(Source: http://www.state.gov/s/inr/rls/4250.htm#note2)
Refused 9--97
Don’t know 9—98
This question is about your ethnicity, your ethnic group and how you feel about it or react to it. Choose the answer to indicate how much you agree or disagree with the following statement.
I have a strong sense of belonging to my own ethnic group
Strongly agree 1
Disagree 2
Agree 3
Strongly agree 4
These questions are about food programs you may participate in.
Do you currently receive benefits from the WIC program, that is, the Women, Infants and Children program?
Yes 1
No 2
Refused 9--97
Don’t know 9--98
Are you or any members of you household authorized to receive Food Stamps (which include a food stamp card or voucher, or cash grants from the state for food)?
Yes 1
No 2
Refused 9--97
Don’t know 9--98
Thank you for your time and participation!
Public reporting burden for this collection of information is estimated to average 6 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 (0925-0590*). Do not return the completed form to this address.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Nutrition LOI Socio-demographics Instrument |
| File Modified | 0000-00-00 |
| File Created | 2021-02-01 |