Form 0920-1154 Written Questionnaire Focus Group

Attachment B. Written Questionnaire Focus Group: Users and Non-Users

Form Approved
OMB No. 0920-1154
Exp. Date 01/31/2020

Public reporting burden of this collection of information is estimated to average 5 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, Georgia 30333; ATTN: PRA (0920-1154).

Focus Group Participant Questionnaire

Please complete this questionnaire. For each question, please check one answer. Please do not include your name.

1. Do you have a driver's license?

 Yes

 No

2. Do you own a car?

 Yes

 No

3. Have you driven in the past two weeks?

 Yes

 No

4. How frequently do you travel outside of your home?

 Once per day, or nearly daily

 Once per week

 Once per month

 Once every few months

 Other frequency: ____________________________

5. Please choose one of the following options that best describes your use of ride share services:

 Never used a ride share service

 Once per day, or nearly daily

 Once per week

 Once per month

 Once every few months

 Once in the last year

 Once or twice ever

 Other frequency: ____________________________

6. Are you of Hispanic or Latino origin?

 Yes, Hispanic or Latino

 No, Not Hispanic or Latino

7. Please choose one or more of the following categories to describe your race:

 American Indian or Alaska Native

 Asian

 Black or African American

 Native Hawaiian or Other Pacific Islander

 White

 Other

8. What is your sex?

 Male

 Female

Participant ID Number: _________