OMB NUMBER: 0584-XXXX
EXPIRATION DATE: XX-XX-20XX
ATTACHMENT B5b: DISCUSSION GROUP PARTICIPANT INFORMATION QUESTIONNAIRE
BURDEN DISCLOSURE 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 0584-XXXX. The time required to complete this information collection is estimated to average 4 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.
Please complete this questionnaire. The information will be used only to summarize participant information at this meeting. Please DO NOT write your name or address on this questionnaire.
Site: _____________________________________ Date: ________________________
Time: ________________________
1. I am:
___ Male
___ Female
2. My age is:
__ 17 years or less
__ 18-25 years
__ 25-29 years
__ 30-39 years
__ 40-49 years
__ 50-59 years
__ 60 or above
3. Number of children (under age 18) living with me:_________
Total number of people living with me:_________
I am currently:
__ Not employed
__ Working less than 20 hours a week
__ Working more than 20 hours a week
I currently participate in:
__ Food Distribution Program on Indian Reservations (FDPIR).
__ Supplemental Nutrition Assistance Program (SNAP)/Food Stamps
__ A nutrition assistance program other than FDPIR or SNAP/Food Stamps.
Program: _____________________________________
__ No nutrition assistance programs
I currently reside:
__ Within a [reservation/tribal service area].
Name of [reservation/tribal service area]: _______________
__ Outside of a [reservation/tribal service area]
My household owns 1 or more automobiles.
__ Yes
__ No
THANK YOU FOR YOUR HELP!
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 4 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Biess, Jennifer |
| File Modified | 0000-00-00 |
| File Created | 2021-01-29 |