Respondent Data

Attachment 5a – PRAMS Respondent Data Collection Sheet (English version)

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 06/30/2015

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 Ad: Flyer: Word of Mouth:

 Gazette  Giant  Friend

 Sentinel  Safeway  Co-worker

 Washington Post/Express  Other  We called you to come back

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

Attachment 5b – PRAMS Respondent Data Collection Sheet (Spanish version)

DEPARTMENT DE SALUD Y SERVICIOS HUMANA Centros para Control Y Prevencion de Enfermedades

Centro Nacional de Estadisticas de Salud

3311 Toledo Road

Hyattsville, Maryland 20782

Para nuestros archivos le solicitamos que llene este formulario.

1. Sexo:

 Masculino  Femenina

2. Cuál es su fecha de nacimiento?

Mes Dia Ano

Fecha: ____/___/___

3. Cuál es su estado civil?

 Casado / en pareja  Divorciado  Viudo  Separado  Soltero

4. ¿Es Ud. hispano, o latino?

 Si  No

5. ¿Cuál es su raza? Señalen uno o más razas para indicar cómo se considera.

 Indígena o Indígena de Alaska

 Asiático

 Negro o Afro-Americano

 Indígena de Hawai u otro de las Islas del Pacifico

 Blanco

(Subject may give other terms such as mestizo; quiz!)

6. ¿Cuál es el último grado o ańo que completo en la escuela?

9 o menos

10

11

12 ( sin diploma)

(At this point quiz them since education system is not equivalent in Latin America)

 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)

7. ¿Tiene empleo?

 Si  No

8. ¿Cuánto es la ganancia o ingreso total de su hogar?

 20Mil o menos  30Mil o menos  mas de 30Mil

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