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Exit Survey
 
 
Demographics
 
 
 
How old are you?
   
 
 
 
How would you describe your race/ethnicity?
 
American Indian/Alaska native
 
Asian
 
Black, non-Hispanic
 
Hispanic
 
 
 
What language do you feel most comfortable speaking?
 
English
 
 
 
I am
 
Male
 
Female
 
Transgender M to F
 
Transgender F to M
 
Don't know
 
Refused
 
Missing
 
 
 
Education, Income & Employment
 
 
 
What is the highest level of education you completed?
 
8th grade or less
 
Some college
 
Some high school
 
College degree
 
High School / GED
 
Graduate school or Vocational Training
 
 
 
What best describes your work situation in the last 6 months?
 
 
 
Medical History / Perceived Health