Focus Group Demographic Profile Questionnaire

ATTACHMENT 3C

Focus Group Demographic Profile Questionnaire

CMV Focus Group Demographic Profile Questionnaire

1. How old are you?

2. Are you currently pregnant?

• Yes

• No

IF NO, Do you plan to get pregnant within the next
12 months?

• YES

• NO

3. What is the highest level of education you have completed?

• Less than high school

• High school diploma or GED

• Technical college/Associates degree

• Some college

• College degree

• Graduate degree

4. What level best describes your total household income?

_ <15,000

_ $15,000 - $29,000

_ $30,000 - $49,000

_ $50,000 - $74,999

_ $75,000 - $150,000

_ $150,001 to $200,000

_ More than $200,000