Questionnaire for Discussion Groups
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1
. Please provide some basic information about yourself.
Please provide some basic information about yourself.
Name:
ZIP:
Email Address:
Phone Number:
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2
. Are you male or female?
Are you male or female?
Male
Female
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3
. What is your age?
What is your age?
Under 16
16 to 29
30 to 44
45 to 59
60 and above
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4
. Which of the following best describes your racial or ethnic group?
Which of the following best describes your racial or ethnic group?
African-American
Asian
Caucasian, European, or white
Hispanic or Latino
Other
Other (please specify)
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