Focus Group TANF participant form

Appendix 6.5 – TANF Participant Form

OMB 0970-XXXX

Expiration Date: XX/XX/XXXX

FOCUS GROUP

PARTICIPANT INFORMATION FORM

Please complete this form. The information will be used only to summarize participant information at this meeting. Please DO NOT write your name or address on this form.

LOCATION____________________________ DATE__________

1. I am:

___ Male

___ Female

2. My age is:

__ 17 years or less

__ 18-25 years

__ 25-29 years

__ 30-39 years

__ 40-49 years

__ 50-59 years

__ 60 or above

3. Number of children (under age 18) living with me:_________

4. Total number of people living with me:_________

4. I am currently:

__ not employed

__ working less than 20 hours a week

__ working more than 20 hours a week

4. I currently participate in an employment or skills training program.

__ Yes

__ No

4. I currently reside:

__ within the reservation

__ outside of the reservation

4. My household owns 1 or more automobiles.

__ Yes

__ No

THANK YOU FOR YOUR HELP!