Community Violence Focus Group Screening

Attachment 8: CV FGD Screening Form

OMB Control No. 0920-1154

Exp. Date 3/31/2026

The public reporting burden of this collection of information is estimated to average 2 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 (0920-1154).

Thank you for your interest in participating in a focus group discussion. First, we need to know a few things about you. The information you provide in this form will be kept confidential – only [consultancy] staff will have access to it, we will store it in a database on a secure server with password protection, and we will destroy all data after focus groups are finished and the study is over.

In order to protect your confidentiality, please do not give us your full name. Instead, please choose a nickname that we can use.

Nickname: __________________________________________________________________

Please provide your email: _____________________________________________________

Are you able to attend a focus group discussion on [insert date, time] via Zoom:

___ Yes

___ No

Can you speak and understand conversations in English?

___ Yes

___ No

[If No, skip to the end of the survey]

Please answer the following questions about yourself:

1. Are you:

(Mark all that apply)

__ Female

__ Male

__ Transgender, non-binary, or another gender

2. Please tell us which Ethnicity describes you:

__ Latino or Hispanic

__ Not Latino or Hispanic

3. Please tell us which Race describes you (select all that apply):

___ American Indian or Alaska Native

___ Asian

___ African American or Black

___ Native Hawaiian or Other Pacific Islander

___ White

4. Do you live with another person?

__ Spouse or romantic partner

__ Family or friend

__ I do not live with anyone

__ Other

5. Do you have, live with, and/or raise any children?

___ Yes

___ No

6. Do you own any firearms/guns?

___ Yes

___ No

7. What is your age?

   1. under 18 years of age

   2. 18-24 years of age

   3. 25-34 years of age

   4. 35-44 years of age

   5. 45-54 years of age

   6. 55-64 years of age

   7. 65-74 years of age

   8. 75 years of age or older

8. What is the highest degree or level of school you have completed? (If you’re currently enrolled in school, please indicate the highest degree you have received.)

___ Less than high school diploma

___ High school degree or equivalent (e.g. GED)

___ Some college, no degree

___ Associate or Bachelor’s degree

___ More than a Bachelor’s degree (e.g. Master’s or Doctoral degree)

9. Generally speaking, do you think of yourself as a Democrat, a Republican, an independent, or something else? Select one.

__Democrat

__Republican

__Independent

__Something else

__Prefer not to answer

10. How would you describe the community that you live in:

___ Urban

___ Suburban

___ Rural