Demographic Sheet

Attachment 5 – Respondent Data Collection Sheet (specific for this study)

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 07/31/2018

Respondent Data Collection Sheet

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?

Newspaper Ad: Flyer: Word of Mouth:

 Gazette  Giant  Friend

 Sentinel  Safeway  Co-worker

 Washington Post/Express  Other  We called you to come back

2. Are you male or female?

 Male  Female

3. What is your age?

_______________

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