Form 6 Demographic, Health and Preference Qx

Attachment 7:

Demographic, Health, and Preference Questionnaire for

Food Reporting Comparison Study (FORCS)

OMB #: 0925-0605

Expiry Date: 10/31/2011

STATEMENT OF CONFIDENTIALITY

Collection of this information is authorized by The Public Health Service Act, Section 412 (42 USC 285 a-1). Rights of study participants are protected by The Privacy Act of 1974. Participation is voluntary, and there are no penalties for not participating or withdrawing from the study at any time. Refusal to participate will not affect your benefits in any way. The information collected in this study will be held in professional confidence. Names and other identifiers will be separated from information provided and will not appear in any report of the study. Information provided will be combined for all study participants and report as statistical summaries.

NOTIFICATION TO RESPONDENT OF ESTIMATED BURDEN

Public reporting burden for this collection of information is estimated to average 15 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 (0925-0605). Do not return the completed form to this address.

Thank you for providing us with information about the foods you ate. Please answer some questions about your experience in providing us this information as well as about yourself.

Please tell us your experience with reporting food intake by phone and computer:

	Phone only	Computer only	Both the same
Did you prefer to report your food intake on the computer, on the phone, or were they both the same?			
Was it easier for you to report your food intake on the computer, on the phone, or were they both the same?			
Do you think you gave more accurate information about your food intake on the phone, on the computer, or were they both the same?			
For which approach did you feel like you had more control over the time of day you reported your food intake? On the phone, on the computer, or were they both the same?			
When providing information about your food intake, was it easier for you to get help with your questions on the phone, on the computer, or they were both the same?			
If you had a choice in terms of how to provide information about your food intake, would you choose the phone or the computer?			

Please tell us about yourself …

2. During the past 12 months, did you take any vitamin or mineral supplements of any kind? Include vitamin or mineral pills, liquids, or tinctures. Do NOT include vitamin fortified foods.

Yes …………
No ………….

2. Do you get much exercise in things you do for recreation (sport, or hiking, or anything like that), or hardly any exercise, or in between?

Much exercise …………
Moderate exercise ….
Little or no exercise …

2. In your usual day, aside from recreation, are you physically very active, moderately active, or quite inactive?

Very active ……………..
Moderately active …..
Quite inactive …………

2. Have you smoked 100 or more cigarettes during your entire life?

No ………….

Y es ………… Do you currently smoke cigarettes or have you stopped?

Currently smoke……

Stopped …………………

How long ago did you stop?

< 1 year ago………..……..

1-4 years ago ……….……

5-9 years ago …………..…

10 or more years ago …

2. Over the past 12 months, did you drink alcoholic beverages such as beer, wine or wine coolers, liquor or mixed drinks?

No …………. (SKIP TO QUESTION 9)

Y es ………… How often did you drink alcoholic beverages?

Never …….…………………....…..

1 time per month or less …..

2-3 times per month .….…..…

1-2 times per week ……………

1 time per day ………….….…

2-3 times per day …….…….…

4-5 times per day ……….………

2. In the past 7 days, how many times did you eat fast food? Include fast food meals eaten at work, at home, or at fast-food restaurants, carryout or drive through.

__________# OF TIMES IN PAST 7 DAYS

2. What is your current marital status or domestic relationship?

Married ………………………………………………………..
Living as married, in a civil union or domestic partnership … ……………………………………………….
Divorced or separated and not living with a spouse or partner …………………………………………
Widowed ……………………………………………………..
Single, never married …………………………………..

2. What is your current living arrangement?

Alone …………………………………………………………
With spouse/partner … ……………………………..
With other family member or person ………..
Nursing home/Assisted living facility …………
Other ………………………………………………………..

2. What is the highest level of education you have completed?

8th grade or less ……………………………………………………………………………………………………………….
Some high school …………………………………………………………………………………………………………….
Earned GED (Graduate Equivalency Degree) ……………………………………………………………………
Completed high school …………………………………………………………………………………………………….
Some college …………………………………………………………………………………………………………………….
Post high-school training other than college (for example vocational or technical training)
Completed a two-year college degree (Associates Arts or Associate Sciences Degree) …….
Completed a four-year college degree (for example BA, BS, RN degree) ………………………….
Some graduate or professional school after college but no degree ………………………………….
Completed graduate/professional school after college …………………………………………………..

2. What is your current annual household income?

Less than $25,000 ………………………………………………….
$25,000 – $49,999 …………………………………………………
$50,000 – $74,999 …………………………………………………
$75,000 – $99,999 …………………………………………………
$100,000 - $149,999 ………………………………………………
$150,000 and more ……………………………………………….

THANK YOU.

We will mail you $30.00 as a token of our appreciation for completing this very important study.

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