Pre-Focus Group Survey

Attachment 13A

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx

Resident Pre-Focus Group Demographic and Attitudinal Survey

Public reporting burden of this collection of information is estimated to average 5 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 CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx)

RESIDENT PRE-FOCUS GROUP SURVEY QUESTIONS

Please answer the following questions as best you are able. Your answers will be used to learn more about who took part in this focus group. If you do not want to answer a particular question, please leave it blank and continue with the next one. You are not required to answer these questions but the information you provide helps insure our research applies fairly to all groups of people.

1. When did you move to this apartment complex?

|___|___|___|___|

MONTH YEAR

2. On a scale of 1 to 10, how would you rate this apartment complex as a place to live? 10 is best, 1 is worst.

10	9	8	7	6	5	4	3	2	1
BEST									WORST

3. Would you agree or disagree with the following statements?

	AGREE	SOME DO/ SOME DON’T	DISAGREE
a. The people in this apartment complex know each other well	1	2	3
b. The people in this apartment complex care about each other	1	2	3

4. Have you smoked at least 100 cigarettes in your entire life?

YES 1

NO 2

5. Do you now smoke cigarettes every day, some days, or not at all?

EVERY DAY 1

SOME DAYS 2

NOT AT ALL 3

6. During the past 12 months, were you regularly exposed to tobacco smoke from other people at home?

YES 1

NO 2

7. Among your close friends, do…

All of them smoke, 1

Most of them smoke, 2

Most of them do not smoke, or 3

None of them smoke? 4

8. In what situations is smoking allowed in your residence?

	YES	NO	DK
a. There are no restrictions about smoking	1	2	-8
b. Allowed in some places or at some times	1	2	-8
c. Not allowed at any time	1	2	-8

9. Has a doctor, nurse, or other health professional ever told you that you had any of the following?

	YES	NO	UNSURE
a. Asthma?	1	2	3

9a1. Do you still have asthma?

YES 1

NO 2

NEVER HAD ASTHMA 3

	YES	NO	UNSURE
b. COPD, or chronic obstructive pulmonary disease, emphysema, or chronic bronchitis?	1	2	3
c. Heart attack, also called a myocardial infarction?	1	2	3
d. Angina or coronary heart disease?	1	2	3

10. What is your sex?

MALE 1

FEMALE 2

11. What is your age?

18-29 1

30-39 2

40-49 3

50-59 4

60-69 5

70 or older 6

12. How many children less than 18 years of age live in your household?

NUMBER OF CHILDREN |___|___|

13. Are you of Latino or Hispanic origin?

YES 1

NO 2

14. Which race(s) do you identify with? (Respondent may select one or more from a-e; f is a recording option for interviewer user only)

a. White? 

b. Black/African-American? 

c. Asian? 

d. Native Hawaiian or Pacific Islander? 

e. American Indian or Alaska Native? 

f. Other race? 

(SPECIFY)