0920-17AUC Attach 3 Telephone Screener vcb 051017kw no confid pld u

Attachment 5: Respondent Data Collection Sheet

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