1.3 Survey

ATTACHMENT 5 COGNITIVE INTERVIEW SCREENER OMB NUMBER: 0925-XXXX

EXPIRATION DATE: XX/XX/XXXX

Cognitive Interview Screener

ID CODE

___ ___ ___ __

Date of Birth

|___|___| |___|___| |___|___|___|___| (ineligible if < 18)

MM DD YYYY

Mother with child or children ages 0-5 [ ] YES [ ] NO (ineligible if no)

1. Are you Hispanic, Latina, or of Spanish origin?
(One or more categories may be selected)

1. ____No, not of Hispanic, Latino/a, or Spanish origin

2. ____Yes, Mexican, Mexican American, Chicano/a

3. ____Yes, Puerto Rican

4. ____Yes, Cuban

5. ____Yes, another Hispanic, Latino, or Spanish origin

2. What is your race?
(One or more categories may be selected)

1. ____White

2. ____Black or African American

3. ____American Indian or Alaska Native

4. ____Asian Indian

5. ____Chinese

6. ____Filipino

7. ____Japanese

8. ____Korean

9. ____Vietnamese

10. ____Other Asian

11. ____Native Hawaiian

12. ____Guamanian or Chamorro

13. ____Samoan

14. ____Other Pacific Islander

3. How well would you say you speak English?

Not at all A little Pretty Well Extremely Well

Low English Proficiency English Proficiency

4. Were you born in the United States? [ ] YES [ ] NO

5. Were your parents born in the United States?

MOTHER [ ] YES [ ] NO

FATHER [ ] YES [ ]NO

6. What is the highest degree or level of school that you have completed?

 Less than a high school diploma or GED

 High school diploma or GED

 Some college but no degree

 Associate Degree

 Bachelor’s degree

 Post-graduate degree

 Refused

 Don’t know

Public reporting burden for this collection of information is estimated to average 2 minutes 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-XXXX). Do not return the completed form to this address.