2.2 Goal 2 Home Visit Demographics

Attachment 2c Goal II Home Visit Demographics Questionnaire OMB #: 0925-0647

Expiration Date: 01/31/2015

ID: ________________________

------------------------------------------------------------------------------------------------------------------------------------------

Home Visit Demographics Questionnaire

------------------------------------------------------------------------------------------------------------------------------------------

Subject:	MOTHER	BABY
Sex:	(Female)	 Male  Female
Age:	______ years, _____ months	______ years, _____ months
Race/ethnic background (CHOOSE ALL THAT APPLY):	1. Are you Hispanic, Latino/a or Spanish origin (One of more categories may be selected)  1. No, not Hispanic, Latino/a, or Spanish Origin  2. Yes, Mexican, Mexican American, Chicano/a  3. Yes, Puerto Rican  4. Yes, Cuban  5. Yes, Another Hispanic, Latino/a or Spanish origin 2. What is your race? (Choose all that apply)  1. White  2. Black or African American  3. American Indian or Alaska Native  4. Asian Indian  5. Chinese  6. Filipino  7. Japanese  8. Korean  9. Vietnamese  10. Other Asian  11. Native Hawaiian  12. Guamanian or Chamorro  13. Samoan  14. Other Pacific Islander	1. Are you Hispanic, Latino/a or Spanish origin (One of more categories may be selected)  1. No, not Hispanic, Latino/a, or Spanish Origin  2. Yes, Mexican, Mexican American, Chicano/a  3. Yes, Puerto Rican  4. Yes, Cuban  5. Yes, Another Hispanic, Latino/a or Spanish origin 2. What is your race? (Choose all that apply)  1. White  2. Black or African American  3. American Indian or Alaska Native  4. Asian Indian  5. Chinese  6. Filipino  7. Japanese  8. Korean  9. Vietnamese  10. Other Asian  11. Native Hawaiian  12. Guamanian or Chamorro  13. Samoan  14. Other Pacific Islander

Thank you very much!

Public reporting burden for this collection of information is estimated to average 2 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 (0925-0647*). Do not return the completed form to this address.