Appendix 6 5_TANF participant form

Urban Institute Study of Tribal TANF Programs Revised 08/07/2012

OMB # 0970-XXXX

Expiration Date: XX/XX/XXXX

FOCUS GROUP

PARTICIPANT INFORMATION FORM

Please complete this form. The information will be used only to summarize participant information at this meeting. Please DO NOT write your name or address on this form.

LOCATION____________________________ DATE__________

1. I am:

___ Male

___ Female

2. My age is:

__ 17 years or less

__ 18-25 years

__ 25-29 years

__ 30-39 years

__ 40-49 years

__ 50-59 years

__ 60 or above

3. Number of children (under age 18) living with me:_________

4. Total number of people living with me:_________

5. I am currently:

__ not employed

__ working less than 20 hours a week

__ working 20 hours or more a week

4. I currently participate in an employment or skills training program.

__ Yes

__ No

4. I currently reside:

__ within the reservation

__ outside of the reservation

4. My household owns 1 or more automobiles.

__ Yes

__ No

THANK YOU FOR YOUR HELP!

THE PAPERWORK REDUCTION ACT OF 1995:  Public reporting burden for this collection of information is estimated to average 120 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, 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.