Form 1 Demographics

Attachment 1: Socio-demographic Information Collected

Public reporting burden for this collection of information is estimated to average 30 minutes per respondent, 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-xxxx*). Do not return the completed form to this address.

Validation Study Demographics

• Age

• Race

  • Select all that apply: American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Pacific Islander, White, Unknown, refused

• Are you of Hispanic or Latino origin?

  • Select: Yes, No, refused

• Gender

  • Select: Male, Female, or refused

• Marital Status

  • Select: Never married, Married, Living with a partner in a committed relationship, Separated, Divorced, Widowed, refused

• Education

  • Select: Less than high school diploma, High school graduate, Associate's degree, Vocational Training, Some college – no degree, College or more, refused

• Zip Code

• Date you became unable to work (mm/yyyy)

• “Are you unable to work mainly due to a physical condition, a mental condition, or both”)

PHYSICAL CONDITION......................................      1       

MENTAL CONDITION........................................      2       

BOTH...............................................................       3        (put into group that needs more completed surveys)

NEITHER..........................................................       4        (End)

REFUSE............................................................       7        (End)

DON’T KNOW..................................................       8        (End)

• Do you currently receive disability benefits? Please check all that apply:

-SSI

-SSDI

-Workers Compensation

-Other:______________

2