Attachment L--Adolescent.Demographics

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

Date

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Participant ID
ATTACHMENT L
PARTICIPANT DEMOGRAPHIC INFORMATION
ADOLESCENT GROUP

Your responses will be kept confidential to the extent permitted by law, including AHRQ’s
confidentiality statute, 42 USC 299c-3(c). That law requires that information collected for
research conducted or supported by AHRQ that identifies individuals or establishments be
used only for the purpose for which it was supplied unless you consent to the use of the
information for another purpose.

1. Gender

 Male
 Female
2. Language

 English
 Spanish
 Spanish and English
 Some other language (Specify)
3. Date of Birth

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Public reporting burden for this collection of information is estimated to average 90 minutes per
response, the estimated time required to complete the survey. 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. Form Approved: OMB Number 0935-XXXX Exp. Date
xx/xx/20xx. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden, to: AHRQ Reports
Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540
Gaither Road Room # 5036 Rockville MD 20850