Appendix J2 Focus Group Postcard

CONTENT OF FOCUS GROUP POSTCARD SIDE 1

O MB Approval No: 0990-NEW

Approval Expires: xx/xx/20xx

Card number

Filled by office Office number: ____ Sheet number: ____ Line number: ____

Name: _________________________________________________________ Address: ____________________________________________________________ City, State, Zip: _______________________________________________________ Primary telephone number: ( _ _ _ ) _ _ _ - _ _ _ _ Alternate telephone number: ( _ _ _ ) _ _ _ - _ _ _ _ Email address: ____________________@ ____________________________ Do you prefer to be contacted by : [ ] phone [ ] email

CONTENT OF FOCUS GROUP POSTCARD SIDE 2

Please mark these three items about yourself.

Gender (please check one):

[ ] Male

[ ] Female

Age group (please check one):

[ ] 18 - 64 years

[ ] 65 years or older

Race/ethnicity (please mark one or more):

[ ] American Indian or Alaska Native

[ ] Asian

[ ] African American/Black

[ ] Native Hawaiian or other Pacific Islander

[ ] White

[ ] Hispanic or Latino/Latina

J.5