Form Approved
OMB No. 0955-0002
Exp. Date XX/XX/2015
Participant Questionnaire
What is your gender?
Male
Female
What is your age?
Under 30
30-34
35 to 44
45 to 54
55 to 64
65+
Do you read and speak English fluently at home?
Yes
No
Are you married?
Yes
No
Do you have any children under the age of 18?
Yes, how many? _____________
No
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 0955-0002. The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer
What is your race? You may select one or more than one category
American Indian or Alaskan Native
Asian
Black or African-American
Hispanic/Latino
Native Hawaiian or other Pacific Islander
White
Other ___________________
What is your current annual household income (the total income of all persons who live in your household except for renters and dependents):
Less than $25,000
$25,001 to $50,000
$50,001 to $75,000
$75,001 to $100,000
$100,001 or more
What is the highest level of education you have completed?
Less than high school
High School or GED
Some college or a 2-year college program
College graduate
Graduate school
Do currently work in the healthcare industry?
Yes
No
Have you worked in the healthcare industry in the past two years?
Yes. Please specify: ______________________________________________________________________________________________________________________________________
No
Have you or an underage child seen a physician in the last 6 months?
Yes
No
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Scott Weinstein |
| File Modified | 0000-00-00 |
| File Created | 2021-01-30 |