Questions to be cognitively tested

Attachment 1: Questions to be cognitively tested

The Public Health Service Act provides us with the authority to do this research (42 United States Code 242k). All information which would permit identification of any individual, a practice, or an establishment will be held confidential, will be used for statistical purposes only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or the establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347).

Public reporting burden for this collection of information is estimated to average 60 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CDC/ATSDR Information Collection Review Office; 1600 Clifton Road NE, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0222).

Form Approved OMB #0920-0222; Expiration Date: 07/31/2018

Demographic questions are included for context. Only the race/ethnicity question will be cognitively tested.

1. What is your age?

 

               _________ age in years

2. What is your race or ethnicity?

Mark all boxes that apply AND print ethnicities in the spaces below. Note, you may report more than one group.

• WHITE – provide details below.

  • German

  • Irish

  • English

  • Italian

  • Polish

  • French

  • Print, for example, Scottish, Norwegian, Dutch, etc._________________________________

• HISPANIC, LATINO, OR SPANISH – provide details below.

  • Mexican or Mexican American

  • Puerto Rican

  • Cuban

  • Salvadoran

  • Dominican

  • Columbian

  • Print, for example, Guatemalan, Spaniard, Ecuadorian, etc. ____________________________

• BLACK OR AFRICAN AMERICAN – provide details below.

  • African American

  • Jamaican

  • Haitian

  • Nigerian

  • Ethiopian

  • Somali

  • Print, for example, Ghanaian, South African, Barbadian, etc. ____________________________

• ASIAN – provide details below.

  • Chinese

  • Filipino

  • Asian Indian

  • Vietnamese

  • Korean

  • Japanese

  • Print, for example, Pakistani, Cambodian, Hmong, etc. __________________________________

• AMERICAN INDIAN OR ALASKA NATIVE – provide details below.

Print, for example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Traditional Government, Tlingit, etc. _________________________________________________________________

• MIDDLE EASTERN OR NORTH AFRICAN – provide details below.

  • Lebanese

  • Iranian

  • Egyptian

  • Syrian

  • Moroccan

  • Israeli

  • Print, for example, Algerian, Iraqi, Kurdish, etc. ___________________________________

• NATIVE HAWIIAN OR OTHER PACIFIC ISLANDER – provide details below.

  • Native Hawaiian

  • Samoan

  • Chamorro

  • Tongan

  • Fijian

  • Marshallese

  • Print, for example, Palauan, Tahitian, Chuukese, etc. ________________________________

• SOME OTHER RACE OR ETHNICITY – print details._____________________________________

3. 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

4. What is your current marital status?

• Single, never married

• Married

• Cohabiting (living with partner)

• Separated

• Divorced

• Widowed

 

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