Sample Questions For Omnibus Survey

OMB No. 0925-0530

Exp. Date xx/xx/xxxx

SAMPLE: QUESTIONS FOR OMNIBUS SURVEY

Public reporting burden for this collection of information is estimated to average 1 minute per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0520). Do not return the completed form to this address.

<<Note: NCCAM’s intention is to contribute to, not to create, omnibus surveys. One or two NCCAM questions would appear on a survey containing several other questions and from several other organizations. Below are two sample questions that NCCAM might include in an omnibus survey.>>

1. Have you been diagnosed with diabetes?

• Yes

• No

• Don’t know

• Refused

If “yes”:

2. Do you take vitamins, herbal supplements, or other dietary supplements?

• Yes

• No

• Don’t know

• Refused

2