1 Program Participants Parents Focus Group Background Form

Form Approved OMB No. 0990-XXXX

Expiration Date XX/XX/XXXX

Background Information for Parent/Legal Guardian’s Focus Group

1. What is the age of your daughter? _____________

2. What is your age? ___________

3	Ethnicity:  Hispanic or Latino  Not Hispanic or Latino
4.	Race: (You can choose more than one category.)  American Indian or Alaska Native  Asian  Black or African American  Native Hawaiian or Other Pacific Islander  White

5. I am my daughters’ _____________

 Mother

 Father

 Legal Guardian (Check one below.)

 Grandparent

 Other Relative (Aunt, uncle, cousin)

 Foster Parent

 Other

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
OS/OIRM/PRA
200 Independence Ave., S.W., Suite 531-H
Washington D.C. 20201

Attention: PRA Reports Clearance Officer.

6. What grade is your daughter now? _____________

6. How long has your daughter been participating (or participated) in the _______________ program? _______ (months)

6. Are you currently employed?

 Yes

 No

1. If you are employed, please check whether you work fulltime or part-time.

 Full-time

 Part-time

6. Are you currently in school?

 Yes

 No