ACF Evidence Capacity Support

Instrument 2 Appendix: Program Participant Screening Questions

What is your name?*

What is your phone number?*

What is your email address?*

What is your preferred method of contact? (Phone/email)*

To assign you to a focus group discussion with people from similar backgrounds, we hope you'll answer the following demographic questions. Stars indicate required questions.

What was your status when you came to the U.S.?*

• Refugee

• Other status (specify)

What is your gender?* (I identify as Male/I identify as Female/I identify as something else)

What is your arrival date to the U.S.?* (Month, Year)

What is your country of origin?* (Open text)

Focus groups will be held in different languages. Which is your preferred language for the group you will attend?* (select all that apply)

• English

• Arabic

• Burmese

• Dari

• French

• Oromo

• Spanish

• Swahili

• Tigrinya

• Ukrainian

• Other (specify)

[If preferred language is not English] Would you be comfortable in an English language focus group?

Do you belong to any specific groups in your home country? (This can be an ethnic group, tribe or other category of belonging) (Open text)

Do you prefer focus group participants to be the same gender as you? (Yes/Does not matter to me)

What is your religion? (Open text)

What U.S. city/town and state do you live in? (City – open text, State - dropdown)

On weekdays, please indicate when you are usually available. (Select all that apply.)

• Mornings (9am-noon)

• Afternoons (noon-5pm)

• Early evening (6pm-8pm)

Is there anything else you would like to share with us? (Open text)

* = Required

PAPERWORK REDUCTION ACT OF 1995 (Public Law 104-13) STATEMENT OF PUBLIC BURDEN: Through this information collection, ACF is gathering information to obtain input from ORR grant recipients and individuals from refugee populations to inform ORR’s theory of change and revisions to program performance reporting, including measures and processes. Public reporting burden for this collection of information is estimated to average 4 minutes per respondent, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a voluntary collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0531 and the expiration date is 9/30/2025. If you have any comments on this collection of information, please contact Nicole Deterding at [email protected].