Focus Group about Women's Perception of Down Syndrome -

ATTACHMENT 3

FOCUS GROUP PARTICIPANT QUESTIONNAIRE

Thank you for agreeing to complete this questionnaire. The questions you answer will only be used to describe the types of women who participated in the focus group discussions. Your answers are 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 feel comfortable answering.

1. How old are you?

________

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 finished?

Never attended school or only attended kindergarten
Grades 1 through 8 (elementary)
Grades 9 through 11 (some high school)
Grade 12 or GED (high school graduate)
College 1 year to 3 years (some college or technical school)
College 4 years or more (college graduate)

5. What is your annual household income from all sources?

No income

Less than $5,000
$5,000-$9,999
$10,000-$14,999

$15,000-$19,999

$20,000-$24,999

$25,000-$29,999

$30,000-$34,999

$35,000-$39,999

$40,000-$44,999

$45,000-$49,999

$50,000-or above

6. Do you have a primary care doctor?

Yes

No

7. Do you have health insurance?

Yes

No (Skip  Question 9)

8. What kind of health insurance do you have (Please mark all that apply)

Medicare, a federal govt. program for people age 65 or older and certain disabled people

Medicaid, a state program that helps people w/low income

The military, TRICARE, or the VA

The Indian Health Service

Some other source (please specify) _______________________________________________________

9. 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

10. What is your current occupation?__________________________________

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

___	Married
___	Widowed
___	Divorced
___	Separated
___	Never married

12. Have you ever been pregnant?

Yes

No (Skip  Question 16)

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

13. Have you given birth to any children?

Yes

No (Skip  Question 16)

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

14. What was your age when you had your first child?___________

15. Were you screened during pregnancy for any conditions such as Down syndrome? [For women with children only]

Yes

No

16. Do you want to have children or more children in the future?

Yes

No

If YES – when do you want to have your next baby?

Within the next 12 months	1
Within 1-2 years	2
After 2 years	3

17. Do you have a family history of:

Down syndrome	Yes No
Mental retardation	Yes No