Participant Questionnaire

Attachment 4 -- Focus Group Participant Questionnaire

Thank you for agreeing to complete this questionnaire. The questions you answer will only be used to describe the focus group participants, so we know which types of women participated in the discussions with us. Your answers are confidential and anonymous. Please do not put your name anywhere on the questionnaire.

Completing this questionnaire is completely voluntary. Please skip any question that you do not want to answer.

_____________________________________________________________________________

1. What is your age? ___ ___ years

2. Are you Hispanic or Latina? Yes No

3. Which of the following categories describe your race? Please circle “Yes” for all that apply to you.

American Indian or Alaskan Native	Yes	No
Asian/Asian American	Yes	No
Black or African American	Yes	No
Native Hawaiian or Other Pacific Islander	Yes	No
White	Yes	No

4. What is the highest grade or year of school you completed? ________________________

5. What was your total combined family income over the past 12 months? Please check one of the following and include money from jobs, social security, retirement income, unemployment payments, public assistance, and so forth. Also include income from interest, dividends, net income from business, farm, or rent, and any other money income received.

___	Less than $20,000
___	$20,000 to $40,000
___	$40,001 to $60,000
___	$60,001 to $80,000
___	$80,001 to $100,000
___	More than $100,000

6. Are you currently: (Please circle “Yes” for all that apply)

Employed for wages	Yes	No
Self-employed	Yes	No
Out of work for more than one year	Yes	No
Out of work for less than one year	Yes	No
A homemaker	Yes	No
A student	Yes	No
Retired	Yes	No
Unable to work	Yes	No

7. Are you currently: (Please check which status best fits you)

___	Married
___	Widowed
___	Divorced
___	Separated
___	Never married

8. Are you currently covered by health insurance? Yes No

9. Are you currently covered by Medicaid? Yes No

10. Have you ever been pregnant? Yes No

If YES – how many times have you been pregnant? _____ Times

11. Have you given birth to any children? Yes No

If YES – how many children have you given birth to? _____ Children

12. Are you currently in a sexual relationship? Yes No

13. Of the following, which is the main method of birth control you used during the last 6 months? Please check ONE of the following:

___	I didn’t use any birth control regularly.
___	Surgical (partner’s vasectomy, tubal ligation, hysterectomy, etc.)
___	Hormone (birth control pill, Norplant, Dep-Provera)
___	Barrier (condoms, diaphragm, sponge, cervical cap)
___	Abstinence (not currently sexually active)
___	Rhythm method (periodic abstinence) OR Withdrawal
___	Other – SPECIFY: ______________________

14. Which of the following best describes your pregnancy plans? Please check one of the following:

___	I am currently pregnant
___	I am currently trying to get pregnant
___	I am not currently trying to get pregnant, but I am planning to get pregnant in the next year or so
___	I am not planning pregnancy in the next year or so, but I plan to at some time in the future.
___	I do not plan to get pregnant at any time in the future.
___	I cannot get pregnant (post-menopausal, tubal ligation, hysterectomy)

For the following questions, one drink is equivalent to a 12-ounce beer, a 5-ounce glass of wine, or a drink with one shot of liquor.

15. During the past 30 days, have you had at least one drink of any alcohol beverage such as beer, wine, a malt beverage, or liquor?

Yes No (SKIP TO END OF QUESTIONNAIRE)

16. During the past 30 days, how many of those days did you have at least one drink of any alcohol beverage?

_________

Days

17. During the past 30 days, on the days that you drank, about how many drinks did you drink on the average?

_________

Drinks

18. Considering all types of alcohol beverages, how many times during the past 30 days did you have 4 or more drinks on an occasion?

_________

Times

Thank you for participating in the focus group discussion and answering the questions on this questionnaire. Please return your questionnaire to the envelope provided.