National Firefighter Registry

Attachment E

Form Approved

OMB No. 0920-0572

Expiration Date 8/31/2021

(To be Completed at Start of FG)

Focus Group Demographics

Background Information

1a. Gender:

• Male

• Female

2a. In which of the following categories does your age fall:

• under 18 years of age

• 18-24 years of age

• 25-34 years of age

• 35-44 years of age

• 45-54 years of age

• 55-64 years of age

• 65-74 years of age

• 75 years of age or older

4a. What is the highest level of education you have completed?

• Grade school

• Less than high school graduate/some high school

• High school graduate or completed GED

• Some college or technical school

• Received four-year college degree

• Some post graduate studies

• Received advanced degree

• Other: _____________________

8a. In what state, city, and zip code do you currently live?

City _______________________ State ____________________ Zip _____________

The public reporting burden of this collection of information is estimated to average 10 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 NE, MS D-74, Atlanta, Georgia 30333 ATTN: PRA (0920-0572).

12a. What is your marital status?

• Married

• Unmarried living with a partner

• Divorced

• Widowed

• Separated, or

• Single, never been married

13a. Which of the following categories best describe your total, annual household income?

• Under $20,000/year

• $20,001 - $30,000/year

• $30,001 - $40,000/year

• $40,001 - $50,000/year

• $50,001 - $60,000/year

• $60,001 - $80,000/year

• $80,001 - $100,000/year

• Over $100,000/year

14a. Number of children (under age 18) living in the household: • None

• 1-2 children

• 3-4 children

• 5 or more children

5a. Please tell me your race or ethnic background. Do you consider yourself?

Ethnicity:

• Hispanic or Latino

• Not Hispanic or Latino

Race:

• White/Caucasian

• Black or African-American

• American Indian or Alaska Native

• Native Hawaiian or Other Pacific Islander

• Asian

• Vietnamese

• Cambodian

• Filipino
• Japanese

• Korean

• Chinese

33a. Do you now smoke cigarettes every day, some days, or not at all? Every day

• Some days

• Not at all

35a. About how long has it been since you completely quit smoking cigarettes?

_____ Days _____ Weeks _____ Months _____ Years

44a. Do you have Cancer? Yes or No

45a. For how long have you had cancer? _________________

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What kind of fire department do you work for? _________________________

How many firefighters are in your fire department? ___________________________

Name (optional) ________________________________________________