Respondent Data Collection Sheet

Att N Resp data collect sheet.doc

NCHS Questionnaire Design Research Laboratory

Respondent Data Collection Sheet

OMB: 0920-0222

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Attachment N: Respondent Data Collection Sheet

DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service

Centers for Disease Control and Prevention

National Center for Health Statistics

3311 Toledo Road

Hyattsville, Maryland 20782


OMB# 0920-0222; Approval expires 6/30/2015



Respondent Data Collection Sheet


This form asks for basic information about you. At the end of the study, your information will be combined with information from other people in the study and will help us form a picture of the characteristics the people who participated in our study. For our records we would appreciate it if you would take a minute to fill out this form.



1. How did you hear about us?

Washington Post/Express  Craigslist  Email list

Flyer  We called you to come back  Friend


2. What is your gender?

 Male  Female  Other _____________


3. What is your age?

_________


4. What is your marital status?

 Married  Divorced  Widowed  Separated  Never been married  Living with a partner


5. Are you Hispanic or Latino?

 Yes  No


6. What is your race? Mark one or more races to indicate what you consider yourself to be.

 American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or other Pacific Islander

White


7. What is the highest level of school you have completed?

Less than High School (No Diploma or GED)

High School Diploma or GED

Associate Degree

Some College

Bachelor’s Degree

Graduate Degree


8. Are you currently employed?

Yes  No


9. What is your total household income?

$0-19,999  $20,000-$44,999  $45,000-$79,999  $80,000 or more


File Typeapplication/msword
File TitleSupporting Statement for Request for Clearance:
AuthorKaren Whitaker
Last Modified ByCDC User
File Modified2015-01-07
File Created2015-01-06

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