Participant Information form

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 the [region name] area? ________________________

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

3. Are you employed?

• Yes

  • Full time (more than 32 hours per week)

  • Part time

• No

4. Are you a student?

• Yes

  • Full time

  • Part time

• No

5. Which category best describes your total household income for 2010? Please include income from all jobs, public assistance, or social security by anyone in the household, before taxes. (check one)

• Less than $20,000

• $20,000 to $49,999

• $50,000 to $99,999

• $100,000 or more

5. Are you:

• Female, not transgender

• Female, transgender

• Male, not transgender

• Male, transgender

• Gender queer

5. Are you:

• Lesbian

• Heterosexual female

• Gay Man

• Heterosexual male

• Other ____________

8. What is your age? _____________________

9. What is your housing situation?

• Homeowner

• Renter

• Stay with family or friends

• Stay at a shelter or other temporary housing

• Currently have no place to stay

• Other________________

10. How recently have you searched for housing?

• To rent __________ years/months ago

• To purchase __________ years/months ago