VA Form 10-0496a Phone Apps Focus Group Demographic Questionnaire

_D

_{OMB 2900-}0770
Estimated Burden: 5 min.

epartment of Veterans Affairs
_{Veterans Health Administration
Participant Demographic Sheet}

PRA Statement: This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Accordingly, we may not conduct or sponsor and you are not required to respond to a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who complete this survey will average 5 minutes. This includes the time it will take to read information provided and gather the necessary facts to complete the form. Submission of this form is voluntary and failure to respond will have no impact on benefits to which you may be entitled.

1.	What is your date of birth?	month day year
2.	What is your gender?

Male  Female

3. What is your ethnicity or racial background?

 White

 Black or African American

 Asian

 American Indian or Alaska Native

 Native Hawaiian or other Pacific Islander

 Hispanic or Latino yes / no

4. What is your marital status?

 Single

 Married

 Cohabitating with significant other for > 1yr

• Divorced

• Separated

• Widowed

5. What is the highest level of education you have completed?

• High school diploma or equivalent

• Bachelor's degree (B.A. or B.S.)

• Master's degree (M.A. or M.S.)

• Doctoral degree (Ph.D. or Psy.D.)



VA Form 10-0496a
NOV 2012

Medical degree (M.D.)

6. What is your employment or student status?

 Fulltime employed

 Part time employed

 Fulltime Student

 Part time Student

 Homemaker

 Unemployed

 Disabled

 Retired

 Other

7. What is your approximate household annual income?

 Less than 25k

 25 to 50k

 50 to 75k

 75 to 100k

 More than 100k)

_{8. In which of the following deployments (if any) have you served? (Check all that apply)}

 OIF (Iraq)

 Desert Shield/Storm

 Vietnam Era (Non-theater)

 Lebanon

 _Somalia

 OEF (Afghanistan)

 Vietnam Theater

 Grenada

 Panama

 Yugoslavia

 Other Combat Operation ________________________________________

9. Have you ever received treatment for PTSD (including psychotherapy or medication)?

 Yes  No

10. Do you own a Smartphone (e.g., iPhone, Droid, Blackberry)?

 Yes  No

I

VA Form 10-0496a
NOV 2012

f yes, how long have you had a Smartphone? months