0990-PatientPerspective_App J2 Focus Group Postcard

O MB Approval No: 0990-NEW

Approval Expires: xx/xx/20xx

CONTENT OF FOCUS GROUP POSTCARD SIDE 1

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 2Please 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

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 0990- . The time required to complete this information collection is estimated to average one minutes per response, including the time to review instructions, search existing data resources, gather the 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/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

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