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Adult Respondent Data Collection Sheet
ICR 201506-0920-003 · OMB 0920-0222 · Object 65335001.
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
|---|---|
| File Title | Adult Respondent Data Collection Sheet |
| Author | Whitaker, Karen R. (CDC/OPHSS/NCHS) |
| Last Modified By | Writer |
| File Modified | 2016-05-25 |
| File Created | 2026-10-30 |
| Conversion State | complete |
Extracted Text
Attachment 5: Adult Respondent Data Collection Sheet - to be asked of Adults, Parents/Guardians only
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
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