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Name
   
 
 
 
Age:
 
16-18
 
18-25
 
26-40
 
41-60
 
60+
 
 
 
I identify as:
 
man
 
woman
 
_____________
 
prefer not to answer
 
 
 
How many people (including yourself) are in your household?
 
1-3
 
3-5
 
6-8
 
8+
 
 
 
Race
 
Native American
 
Asian
 
Black or African American
 
Native Hawaiian or Pacific Islander
 
White
 
Two or more races
 
Other
 

 
 
 
Are you Spanish/Hispanic/Latino?
 
Yes
 
No
 
 
 
Highest level of education completed:
 
Less than 10th grade
 
Some or all of 10th grade
 
Some or all of 11th grade
 
Some of 12th grade
 
High school diploma
 
GED
 
Trade school
 
Associates (2 yr degree)
 
Bachelors (4 yr degree)
 
Other
 

 
 
 
Tell us about your employment:
 
full-time or more
 
part-time (less than 35 hours per week)
 
self-employed
 
in school, full or part-time
 
homemaker
 
unemployed
 
retired or disabled

 
 
 
 
Helpful to me
Not helpful
 
 
 
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