Form Approved OMB No. 0990-XXXX
Expiration Date XX/XX/XXXX
Background Information for Partners Focus Group
What organization do you represent? _____________
How long has your organization been providing services? ______________
How long has your organization been providing services for girls?________
How long have you been a staff member of your organization? _______ (years)
What is your position in the organization? _______________
Were you involved in providing direct services to participants in the __________________ program? Yes ____ No____
If yes, what service(s) did you provide? _____________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
How long did you provide services, if any, to the ___________________ program?
______________________________
What is your age? ___________
According
to the Paperwork Reduction Act of 1995, no persons are required to
respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this
information collection is XXXX-XXXX. The time required to complete
this information collection is estimated to average 5 minutes per
response including the time to review instructions, search existing
data resources, the gather data needed, and complete and review the
information collection. If you have comments concerning the accuracy
of the time estimate(s) or suggestions for improving this form,
please write to:
U.S.
Department of Health & Human Services Attention:
PRA Reports Clearance Officer.
OS/OIRM/PRA
200
Independence Ave., S.W., Suite 531-H
Washington D.C. 20201
Are you Hispanic or Latino?
Yes, I am
No, I am not
What is the racial category you most closely identify?
American Indian or Alaska Native
Asian or Pacific Islander
Black or African American
White
Other (specify): ___________
Page
| File Type | application/msword |
| Author | GEARS INC |
| Last Modified By | GEARS INC |
| File Modified | 2010-09-14 |
| File Created | 2010-09-14 |