Maricopa County - Focus Groups

ID #

Focus Group Worksheet

2015 Census Test

This information will not be used to contact you. Your response is voluntary and will only be used for research purposes.

1. What is your name?

_________________________________________

Full Name

2. What is your address?

Street number and name: ____________________________________________

Apartment or unit number: ___________________________________________

City: ____________________________________________

State: _____________________

ZIP Code: _________________

3. Please provide a phone number.

( ________ ) - ________ - ___________

4. Please provide an email address.

_______________________________________ @ __________________ . _________

OMB Control Number: 0607-0981 Expires: 3/31/2016