Demo Questions Focus Group Worksheet

OMB Control No. 0690-0030

Expiration Date: 6/30/17

Focus Group Worksheet

Your response to these questions is voluntary.

1. In what year were you born? __________________ year

2. What is the highest grade or year of school you have completed?

• Less than high school

• Completed high school

• Some college, no degree

• Associate’s degree (AA/AS)

• Bachelor’s degree (BA/BS)

• Post-bachelor’s degree (for example, MA, MS, PhD, MD)

3. Are you male or female?

• Male

• Female

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

• Yes

• No

5. What is your race? Choose one or more races.

• White

• Black or African American

• American Indian or Alaska Native

• Asian

• Native Hawaiian or Other Pacific Islander

6. How many people age 16 or older currently live in your household, INCLUDING yourself?

_________

7. How many people younger than age 16 currently live in your household?

_________

8. Do you currently live with all family members, some family members and some non-family members, or all non-family members?

• All family members

• Some family members and some non-family members

• All non-family members

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