Document
Supporting Statement for Request for Clearance:
ICR 201506-0920-003 · OMB 0920-0222 · Object 58505901.
This document may belong to an older filing. More recent activity for OMB 0920-0222:
Document Viewer [doc]
Document Metadata
| File Type | application/msword |
|---|---|
| File Title | Supporting Statement for Request for Clearance: |
| Author | Karen Whitaker |
| Last Modified By | Writer |
| File Modified | 2015-09-08 |
| File Created | 2026-10-10 |
| Conversion State | complete |
Extracted Text
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 7/31/2018 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