Collection Instruments - Individuals

Enhancing Food Stamp Certification: 11/13/07

B-52

FOCUS GROUP
PARTICIPANT INFORMATION FORM
Food Stamp Program Participants and Eligible Nonparticipants
Please complete this form. The information will be used only to summarize participant
information at this meeting. Your name and address are not needed.
LOCATION
1.

________________________ DATE__________

I am a ___Male ___Female

2. My age is:

__less than 20 years

__ 31-40 years __ 56 years+

__21-30 years

__ 41-55 years

3. The languages spoken in my home are: _______________
1st Language
4. My marital status is:
__Never married
__Divorced

_______________
2nd Language

__Married/with partner __Separated
__Widowed

5. Number of children (under age 18) living with me:_________
6. The highest education I completed was:
__Grammar/Elementary School
__Junior High/Middle School
__High School or G.E.D.

__Tech/Vocational School/Bs.College
__Community College
__University (4 year)
__Graduate school

7. I am currently:
__ not employed
__working less than 20 hours per week
__ working more than 20 hours per week
8. I have a disability that limits my ability to work or go outside my home:
__Yes
__No
9. Food Stamp Program participation
Currently on Food Stamps
Ever participated in the Food Stamps

__Yes __No
__Yes __No

THANK YOU FOR YOUR HELP
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information
unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0584-XXXX and
expires on XX/XX/XXXX. The time required to complete this information collection is estimated to average 9.5 minutes, including
the time to review instructions, search existing data resources, gather the data needed, and complete and review the information
collection. If you have any comments concerning the accuracy of the time estimate or suggestions for improving this form, please
write to: U.S. Department of Agriculture, Food and Nutrition Service, ORNA, Alexandria, VA 22302.