Attach 5 - CLAS Resp data sheet

Attachment 5: 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 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. Are you male or female?

 Male  Female

2. What is your age?

_______________

3. Are you Hispanic or Latino?

 Yes  No

4. 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