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CQDER CMS Att 5ab Resp Data Collect
ICR 201506-0920-003 · OMB 0920-0222 · Object 64344701.
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
|---|---|
| File Title | CQDER CMS Att 5ab Resp Data Collect |
| Author | Whitaker, Karen R. (CDC/OPHSS/NCHS) |
| Last Modified By | Writer |
| File Modified | 2016-04-08 |
| File Created | 2026-09-16 |
| Conversion State | complete |
Extracted Text
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