Individual/Households Respondents

ATTACHMENT M.1

PARTICIPANT INFORMATION Survey:

Client Focus Group

english

OMB Control No.: 0584-xxxx

Expiration Date: 00/00/20XX

Client Focus group: Participant information SURVEY

Participant’s Demographics

1. Are you male or female?

• Female

• Male

2. How old are you?

_____ years old

3. Are you…..

• Hispanic or Latino

• Not Hispanic or Latino

4. What is your race?

Mark all that apply.

• American Indian or Alaska Native

• Asian

• Black, African American

• Native Hawaiian or other Pacific Islander

• White

Participant’s Education and Employment History

5. What is the highest level of education you have completed?

• Did not complete high school

• High school/GED

• Some college

• Associate’s degree

• Bachelor’s degree

• Master’s degree or above

6. Are you currently working?

• Yes, full-time (35 hours per week or more)

• Yes, part-time (1 to 35 hours per week)

• No

7. [If not currently working:] How long have you been unemployed?

• Never held a job or looked for work

• 6 months or fewer

• 7 months to 2 years

• More than 2 years

8. Which of the following have made it difficult for you to find or keep work?

Mark all that apply.

• Limited English

• Difficulty reading or writing

• Health problems or disability

• Alcohol and/or drug use

• Criminal record

• Don’t have transportation

• Caring for others (children, parents, other adult relative)

• Lacking needed job skills

• None of the above

Public Burden Statement

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0584-xxxx. The time required to complete this information collection is estimated to average 10 minutes including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate to the Office of Policy Support, Food and Nutrition Service, USDA, 3101 Park Center Drive, Room 1014, Alexandria, VA 22302.