Recruitment, Reminder and Interview-Individuals/Households

OMB Approval No.: 0584-XXXX

Approval Expires: XX/XX/XXXX

Appendix B-5: FOCUS GROUP

PARTICIPANT INFORMATION FORM

Please complete this form. The information will be used only to summarize who participated in this discussion group. Your name and address are not needed.

1. How many years have you lived in this city? ___________________________

2. What is the total number of people living in your household? ____________________

3. How many children younger than 18 live in your household? ____________________

4. Are you employed?

Yes

o Full time (more than 32 hours per week)

o Part time

No

5. Are you a student?

Yes

o Full time

o Part time

No

6. Which category best describes your highest grade completed. (check one)

Less than high school

High School/GED

Some College

Completed College

7. Are you:

Male

Female

8. What is your age? _____________________

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0584-XXXX. The time required to complete this information collection is estimated to average 3 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.