Self-administered questionnaire for focus group participants

OMB Control No.: 0970-xxxx

Expiration Date: xx/xx/20xx

Length of time for questionnaire: 2 minutes

INSTRUMENT 5: SELF-ADMINISTERED QUESTIONNAIRE FOR FOCUS GROUP PARTICIPANTS

Self-Administered Questionnaire for Focus Group Participants

This voluntary questionnaire helps our team learn more about the people who participate in the focus groups. The results will be kept private and not linked to you in any way. Please do NOT include your name. It should take about two minutes to complete the questionnaire.

1. What is your current relationship status? Please circle one.

Married, living with a spouse

Married, not living with a spouse

Living with a partner/boyfriend/girlfriend

In a relationship but not living together

Not in a relationship

Prefer not to answer 

2. Do you have any children?

Yes  If Yes, how many? _____________

No

3. How old are you? _______________ years

4. Are you of Hispanic, Latino, or Spanish origin?

Yes

No

5. What is your race? One or more categories may be selected.

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

Public reporting burden for this collection of information is estimated to average 2 minutes per response. This information collection is voluntary. 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: Urban Institute (Attn: Heather Sandstrom), 2100 M Street, NW, Washington, D.C. 20037

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