Appendix I- Cognitive Interviews - Individual Sign-Up Sheet 24oct13

Appendix I- Cognitive Interviews - Individual Sign-Up Sheet 24oct13.docx

Pre-testing of Evaluation Surveys

Appendix I- Cognitive Interviews - Individual Sign-Up Sheet 24oct13

OMB: 0970-0355

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APPENDIX I:



FPRQ Cognitive Interviews – Individual Sign-Up Sheet


October 24, 2013




Individual Sign-Up Sheet





Sign up here to get more information about a study on relationships between families and Family Service Workers. Your information will remain private to the extent permitted by law.




Name: ___________________________________________


Home Phone Number: _____________________________­­­­­­­_


Cell Phone Number: ­________________________________


Email: ­­­­­­­­­­­­­­­­____________________________________________


Best Time to Reach You: ____________________________

















Please hand your completed sign-up sheet to _______________.


The Paperwork Reduction Act Statement: This collection of information is voluntary and will be used to help develop questions for surveys about relationships between Family Service Workers (FSWs) and the families they work with. Public reporting burden for this collection of information is estimated to average 2.25 hours per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this collection is 0970-0355 and it expires 01/31/2015.

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