QDRL-OMB Attachment E Resp Data Collect Sheet

Attachment E

Respondent Data Collection Sheet

DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service

Centers for Disease Control and Prevention

National Center for Health Statistics

3311 Toledo Road

Hyattsville, Maryland 20782

OMB# 0920-0222; Approval expires [fill date]

Respondent Data Collection Sheet

For our records we would appreciate it if you would take a minute to fill out this form.

1. How did you hear about us?

 Newspaper advertisement  Flyer  Word of mouth

2. Are you male or female?

 Male  Female

3. What is your age?

_________

4. What is your marital status?

 Married  Divorced  Widowed  Separated  Never been married

5. Are you Hispanic or Latino?

 Yes  No

6. What is your race? Mark one or more races to indicate what you consider yourself to be.

 American Indian or Alaska Native

 Asian

 Black or African American

 Native Hawaiian or other Pacific Islander

 White

7. What is the highest grade of school you have completed?

9^th

10^th

11^th

12^th no diploma

 High School Graduate - High School Diploma or the equivalent (for example: GED)

 Some college but no degree

 Associate Degree in college - Occupational/vocational program

 Associate Degree in college - Academic program

 Bachelor’s degree (For example: BA, AB, BS)

 Master’s degree (For example: MA, MS, MEng, MEd, MSW, MBA)

 Professional or Doctorate (for example: MD, PhD, DVM, JD)

8. Are you currently employed?

 Yes  No

9. What is your total household income?

 20K or less  30K or less  over 30K