2 Participant Information Survey

Your Program Name

OMB Control No. 0985-XXXX
Exp. Date XX/XX/201

Participant Information Survey
Instructions: Please use a pen to answer the questions on both sides of this form.
Please print clearly. Mark your choice within the box, like this:
Your Name (or other way to identify you): _______________________________________
1. What is your date of birth?

/
Month

/
Day

Year

2. What is your ZIP code?
3. What is your sex?
Female

Male

4. Are you of Hispanic, Latino, or Spanish origin?
Yes

No

Unknown

5. What is your race? (Mark all that apply.)
American Indian or Alaska Native
Asian
Black or African-American
Native Hawaiian or Other Pacific Islander
White
6. Has a health care provider ever told you that you have any of the following chronic
conditions? (Please mark all that apply.)
Alzheimer’s or Related Dementia
Arthritis/Rheumatic Disease
Breathing/Lung Disease (Asthma,
Emphysema, Bronchitis, etc.)
Cancer or Cancer Survivor
Chronic Pain
Depression or Anxiety Disorders
Diabetes
Heart Disease

High Cholesterol
Hypertension (High Blood
Pressure)
Multiple Sclerosis
Osteoporosis (Low Bone Density)
Stroke
Other Chronic Condition:
___________________________
None (No Chronic Conditions)
Please turn over

PAPERWORK REDUCTION ACT STATEMENT
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 0985-xxx.
The time required to complete this information collection is estimated to average 6 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: Administration for Community Living, 1 Massachusetts Avenue, N.W., Room 5203,
Washington, D.C. 20001, Attention: PRA Reports Clearance Officer

Your Name (or other way to identify you): _______________________________________

7. During the past year did you provide regular care or assistance to a friend or
family member who has a long-term health problem or disability?
Yes

No

8. Are you limited in any way in any activities because of physical, mental, or
emotional problems?
Yes

No

9. Today, how many people live in your household (including yourself)?
(Number of people)

10. What is the highest grade or year of school you completed?
Some elementary, middle, or high school
High school graduate or GED
Some college or technical school
College 4 years or more