Focus Group Residents and Family Members

Focus Group Participant Information Questionnaire
Residents/Family Members
Please complete this questionnaire. This information will be used only for summarizing participant information
at this meeting. Please DO NOT write your name or address on this questionnaire.
Date: ________________________

1. I am the:

Time: ________________________

__ Resident
__ Family member (SPECIFY):__________
__ Friend
__ Guardian
__ Other: ___________________________

2. I live in a (respond on behalf of resident if the respondent is not the resident):

__ Nursing home
__ Board and care home (assisted living, residential care, and other non-nursing home settings)
__ Other: ___________________________

3. I am:

___ Male
___ Female

4. I was born in ____.
5. My marital status is:

__ Single, never married
__ Married or domestic partnership
__ Widowed
__ Divorced
__ Separated

6. I am:

__ American Indian or Alaska Native
__ Native Hawaiian or other Pacific Islander
__ White
__ Black or African American
__ Asian
__ Other (SPECIFY): __________________________

THANK YOU FOR YOUR HELP!
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