Interview Record	AFFACT-504 4-1-2007
Extension Homemakers Clubs	4 – H Units
To determine interest in being a member of an Extension Homemaker Club or a 4 – H Unit. (For use in an interracial membership area.)
1. Name	2. Mailing Address
3. Telephone	4. Membership Area
5. Date of interview	Time of interview
6. Method of interview
7. Race/Ethnicity of Person Interviewed:	Gender of Person Interviewed
8. Number of prospective 4 – H members in the household	(4 – H only)
9. Were the benefits of being a member of EHC / 4 – H explained?
10. Is this person or his / her child interested in becoming a member of EHC / 4-H?
11. Meeting time preference	Weekdays	Evenings	Weekends (EHC only)
12. If not desiring to become a member, why? (Check reason given)
Personal lack of interest in the EHC/4-H program	Lack of time to devote to attending meetings
Inconvenience of meeting location	Inconvenience of time of meetings
Pressure of daily responsibilities	Not interested now, but maybe later
Other (Specify)
13. Type of Unit discussed	County-wide club	Community club	Project club
Project group
Other (Specify)
14. Remarks
Race/Ethnicity of Interviewer	Sex of Interviewer
Signature of Interviewer	Date
NOTE: Submit one copy with AFFACT – 343 to District director. Retain one copy in county files.
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