Demographic Questionnaire

Demographic Questionnaire

Version of January 5, 2014

1. What is your age?

____ 25 or under

____ 26-40

____ 41-55

____ 56 or older

2. What is your gender?

____ Female

____ Male

3. What is the highest level of education you have completed?

____ Grammar school

____ High school or equivalent

____ Vocational/technical school (2 year)

____ Bachelor’s degree

____ Master’s degree

____ Doctoral degree

____ Professional degree (MD, JD, etc.)4. How would you classify yourself?

____ Arab

____ Asian/Pacific Islander

____ Black

____ Caucasian/White

____Hispanic

____ Indigenous or Aboriginal

____ Latino

____Multiracial

____Would rather not say

____ Other _______________________

5. What is your current marital status?

____ Divorced

____ Living with another

____Married

____Separated

____Single

____Widowed

____Would rather not say

6. Which of the following best describes the area that you live in?

____ Rural (no neighbors within ½ mile of your residence)

____ Suburban

____ Urban

7. How many children under 16 years old live in your household?

____ 0

____ 1

____ 2

____ 3

____ 4 or more

End of Demographic Questionnaire

Thank you for your participation in this survey.