OMB control number 0925-0634
Burden Disclosure Statement
Public reporting burden for this collection of information is estimated to average 10 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0634). Do not return the completed form to this address.
Pre-Focus Group Questionnaire
Are you a formal or informal caregiver for an older family member or friend?
Formal
Informal
What is your relationship with this person?
Parent
Grandparent
Sibling
Aunt/Uncle
Cousin
Other ______________________________
Does this person live with you?
Yes
No
Which best describes you:
I have a home computer
I do not have a home computer, but I have access to another computer (such as at a library); I use the computer at:___________________________
I do not have access to a computer
Which best describes your internet access:
Dial-up internet
High speed internet
No internet access (at home or outside of home)
How do you get your health information? (Please check all that apply and, where indicated, please fill in specific details.)
Television; Program Name:__________________________________________
Newspaper; Name: ________________________________________________
Magazine; Name: _________________________________________________
Newsletter; Name: _________________________________________________
Online; Name of Website: ___________________________________________
Radio; Channel:____________________________________________________
Books
Doctor
Family member
Friend
Other; Please explain: ______________________________________________
Before being part of this discussion group, had you heard of the National Institute on Aging (NIA) and/or the National Institutes of Health (NIH)?
Yes, both NIA and NIH
Yes, just NIA
Yes, just NIH
No
What is your ethnicity?
Hispanic or Latino
Not Hispanic or Latino
What is your race? (You can choose more than one)
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
What is your age?
What is the age of the family member/person you find health and aging information for?
File Type | application/msword |
Author | homerme |
Last Modified By | Seleda Perryman |
File Modified | 2012-09-28 |
File Created | 2012-09-28 |