Attachment D
Form Approved
OMB No.: 0920-xxxx
Expiration Date: XX/XX/XXXX
Public Reporting burden of this collection of information is estimated at 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 Reports Clearance Officer, 1600 Clifton Road NW, MS D-74, Atlanta, GA 30333; Attn: PRA (0920-XXXX).
MT General Population Sample
What is your age?
_____ years
What sex were you assigned at birth, on your original birth certificate?
0Male
1Female
Which of the following best represents how you think of yourself?
0 Gay (lesbian or gay)
1 Straight, that is, not gay or lesbian
2 Bisexual
3 Something else
4 I don’t know the answer
What is the highest grade or level of school that you have completed?
0 8th grade or less
1 Some high school, but did not graduate
2 High school graduate or GED
3 Some college or 2-year degree
4 4-year college graduate
5 More than 4-year college degree
What was your total household income during the past 12 months?
0 Less than $10,000
1 $10,000 to $14,999
2 $15,000 to $24,999
3 $25,000 to $34,999
4 $35,000 to $49,999
5 $50,000 to $74,999
6 $75,000 to $99,999
7 $100,000 to $149,999
8 $150,000 to $199,999
9 $200,000 or more
Are you Hispanic or Latino?
0 No
1 Yes
What is your race? Mark one or more.
0 White
1 Black or African American
2 Native Hawaiian or Other Pacific Islander
3 Asian
4 American Indian or Alaska Native
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Huang, Alison |
| File Modified | 0000-00-00 |
| File Created | 2021-01-21 |