Youth Demographic Survey (16+ years)

OMB No: ???: Exp Date: ???

Youth Demographic Supplement

(16 and older)

How many jobs have you held in the last 12 months? N one One Two Three Four Five or more Write the name of your current or most recent job. If you have (or recently had) two jobs at the same time, answer for the job you had the longest. _________________________________________ Do you still have this job? Yes No How much do you earn per hour currently, or did you earn just before you left this job? Less than $5.15 $5.15 -$7.00 $7.01-$9.00 $9.01-$11.00 $11.01-$13.00 $13.01-$15.00 $15.01-$17.00 $17.01 or more

About how many hours per week did/do you usually work in this job? ____________ I n the past 12 months, did you move away from your parent(s)’ house (when we say parent(s), we mean the parent, guardian, or stepparent with whom you lived most of the time) No Yes When did you move? _________ With whom do you currently live? Other parent Other relative Boyfriend/girlfriend Other friend/roommate On your own

Public reporting burden of this collection of information is estimated to average 1 minute 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 Information Clearance Officer; 1600 Clifton Road NE, MS D-24, Atlanta, Georgia 30333; ATTN: PRA (???).

FOR STUDY USE ONLY
Date Interviewed	Month Day Year	Interviewed by