Screener

Form Approved

OMB No. 0920-0919

Exp. Date 01/31/2015

SCREENER

S1.          What is your age?

                _______ years (ELIGIBLE 18-44)

S2. Which of the following statements would best describe you?

• I am currently pregnant (INELIGIBLE)

• I want to get pregnant within the next two years (PLANNERS)

• I don’t want to get pregnant in the next two years but I want to at some time in the future [NON-PLANNERS, CONTEMPLATORS]

• I do not want to get pregnant at any time in the future [NON-PLANNERS]

• I cannot get pregnant (surgical sterilization, tubal ligation, hysterectomy, infertility, menopause) [INELIGIBLE]

S3. Are you Hispanic or Latino?

• Yes

• No

S4. Which of the following categories best describes your race? (check all that apply)

• American Indian or Alaska Native

• Asian

• Black or African American

• Native Hawaiian or Other Pacific Islander

• White

S5. Which of the following categories best describe your total, annual household income?

• Under $20,000/year {ELIGIBLE}

• $20,001 - $30,000/year {ELIGIBLE}

• $30,001 - $40,000/year {ELIGIBLE}

• $40,001 - $50,000/year {ELIGIBLE}

• $50,001 - $60,000/year [INELIGIBLE]

• $60,001 - $80,000/year [INELIGIBLE]

• $80,001 - $100,000/year [INELIGIBLE]

• Over $100,000/year [INELIGIBLE]

The public reporting burden of this collection of information is estimated to average 1 minute 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 - CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333 ATTN: PRA (0920-0919)