0920-16AEE CQDER CMS Att 5ab Resp Data Collect

Attachment 5a: English language - Respondent Data Collection Sheet

Note to reviewers: Cognitive interviews will be conducted in Spanish only. For ease of review, the Respondent Data Collection Sheet is included in both English and Spanish.

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

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. What is your gender?

 Male  Female  Other _____________

2. What is your age?

_________

3. What is your marital status?

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

4. 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

6. 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

7. Are you currently employed?

 Yes  No

8. What is your total household income?

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

Attachment 5b: Spanish language - Respondent Data Collection Sheet

Note to reviewers: Cognitive interviews will be conducted in Spanish only. For ease of review, the Respondent Data Collection Sheet is included in English. See Attachment 5a.

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

Hoja de Recolección de datos del Participante

Este formulario solicita información básica acerca de usted. Al final del estudio, su información será combinada con información de otros participantes del mismo estudio, y nos ayudará a formar una idea de las características de las personas que participaron en nuestro estudio. Para nuestros registros, le agradeceríamos si tomara un minuto para llenar este formulario.

1. ¿De qué sexo es?

 Masculino  Femenino  Otro _____________

2. ¿Cuál es su edad?

_________

3. ¿Cuál es su situación de pareja?

 Casado(a)  Divorciado(a)  Viudo(a)  Separado(a)  Soltero(a)  Viviendo en pareja

4. ¿Es Ud. hispano(a), o latino(a)?

 Sí  No

5. ¿Cuál es su raza? Marque una o más razas para indicar cómo se considera.

 Indio(a) de EEUU o nativo(a) de Alaska

 Asiático(a)

 Negro(a) o afro-americano(a)

 Nativo(a) de Hawái o de otras islas del Pacifico

 Blanco(a)

6. ¿Cuál es el nivel más alto de estudios que ha completado?

 Menos de high school (Sin diploma o GED)

 Diploma de high school o GED

 Grado de asociado

 Algo de estudios de college o universidad

 Grado de licenciatura

 Título de posgrado

7. ¿Está empleado(a) actualmente?

 Sí  No

8. ¿Cuánto es el ingreso anual total de su hogar?

$0-19,999  $20,000-$44,999  $45,000-$79,999  $80,000 o más

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