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Focus Group Data Sheet
OMB#:  0584-NEW
		Expiration Date:  xx/xx/20xx


Public reporting burden for this collection of information is estimated to average 90 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: U.S. Department of Agriculture, Food and Nutrition Services, Office of Research and Analysis, 3101 Park Center Drive, Room 1014, Alexandria, VA 22302 ATTN: PRA (0584-xxxx).  Do not return the completed form to this address.


DATA SHEET FOR FOCUS GROUP PARTICIPANTS
(This sheet will be given to participants after the Focus Group session but prior to receiving their incentive.) 

DATE:  |___|___| / |___|___| /2011


1.	What was the last grade or year of school you completed?
			Did not complete high school
    • High School Graduate
			Trade\Technical\Vocational After High School
    • Some College 
    • College Graduate
			Postgraduate 
		  Other       Please specify: ___________________________________

	1a.	What is the highest degree or certification that you have achieved?
			Highest Degree/Certification: ___________________________________
			Year completed:  |___|___|___|___|

2.	Are you currently working for pay?
		  Yes	(Go to 3)
		  No	(Continue)

	2a.	Are you currently unemployed, that is, not working and looking for work?
		  Yes	(Go to 3)
		  No	(Continue)

	2b.	Are you not working and not looking for work?
		  Yes
		  No

    3. How many people are currently living in your home including family, yourself and any others?

		Enter number: |___|___|

	3a. 	Of these, how many are adults age 18 or older?

		Enter number: |___|___|

	3b.	How many are children between the ages of 5 and 17?

		Enter number: |___|___|

	3c. 	How many are children under five years of age?

		Enter number: |___|___|


    4. Do you consider yourself to be?  
   Hispanic or Latino
   Not Hispanic or Latino

    5. What is your race?  Do you consider yourself to be:
		  American Indian or Alaskan Native
			Asian
    • Black
		  Native Hawaiian or other Pacific Islander
		  White
		  Other       Please specify: ___________________________________



Thank you very much for your participation.
Please return this form to the assistant.