Participant Information Table
County: Location/Site:
1. Native Indian/Alaska Native / 1. 5–18
2. Asian / 2. 19–59
3. Black/African/American / 3. Over 60
4. Native Hawaiian/Pacific Islander
5. White
Yes / No / Yes No / Female / Male / Yes No / 1 2 3 4 5 / 1 2 3
Yes / No / Yes No / Female / Male / Yes No / 1 2 3 4 5 / 1 2 3
Yes / No / Yes No / Female / Male / Yes No / 1 2 3 4 5 / 1 2 3
Yes / No / Yes No / Female / Male / Yes No / 1 2 3 4 5 / 1 2 3
Yes / No / Yes No / Female / Male / Yes No / 1 2 3 4 5 / 1 2 3
Yes / No / Yes No / Female / Male / Yes No / 1 2 3 4 5 / 1 2 3
Yes / No / Yes No / Female / Male / Yes No / 1 2 3 4 5 / 1 2 3
Yes / No / Yes No / Female / Male / Yes No / 1 2 3 4 5 / 1 2 3
Yes / No / Yes No / Female / Male / Yes No / 1 2 3 4 5 / 1 2 3
Yes / No / Yes No / Female / Male / Yes No / 1 2 3 4 5 / 1 2 3
Yes / No / Yes No / Female / Male / Yes No / 1 2 3 4 5 / 1 2 3
Yes / No / Yes No / Female / Male / Yes No / 1 2 3 4 5 / 1 2 3
Yes / No / Yes No / Female / Male / Yes No / 1 2 3 4 5 / 1 2 3
Yes / No / Yes No / Female / Male / Yes No / 1 2 3 4 5 / 1 2 3
Yes / No / Yes No / Female / Male / Yes No / 1 2 3 4 5 / 1 2 3
Yes / No / Yes No / Female / Male / Yes No / 1 2 3 4 5 / 1 2 3
Yes / No / Yes No / Female / Male / Yes No / 1 2 3 4 5 / 1 2 3
Yes / No / Yes No / Female / Male / Yes No / 1 2 3 4 5 / 1 2 3
Yes / No / Yes No / Female / Male / Yes No / 1 2 3 4 5 / 1 2 3
Yes / No / Yes No / Female / Male / Yes No / 1 2 3 4 5 / 1 2 3