Form 1 instrument

Appendix B – Anonymous Demographic Questionnaire

Partial Address: __________________________________________________________________

(Street Name ONLY – Please do not provide number) City Zipcode

1. Do you consider yourself to be Hispanic or Latina/o?

 Yes – Please answer Question 2

 No – Please go to Question 3

 I don’t know – Please go to Question 3

2. Which group best represents your Hispanic origin or ancestry.

 Mexican, Chicano, Mexican American

 Puerto Rican

 Cuban

 Other

 I don’t know

3. What race do you consider yourself to be? You may select one or more.

 White

 Black or African American

 American Indian or Alaska Native





Asian

 Japanese

 Chinese

 Korean

 Vietnamese

 Indian

 Filipino





Native Hawaiian

 Pacific Islander

 Guamanian or Chamorro

 Other

4. What do you consider to be your primary language? _____________________________________

a. In what language do you usually read? ___________________________________

b. In what language do you usually write? ___________________________________

c. In what language do you usually speak at home? ____________________________

d. In what language do you usually speak with friends? _________________________

5. Age: ____________

6. Marital status:

 Single, never married

 Married

 Divorced

 Separated

 Living with a partner/not married

7. How do you identify yourself religiously? Please check all that apply.

 None

 Buddist

 Catholic

 Christian

 Episcopalian

 Jehovah’s Witness

 Jewish

 Mormon

 Muslim

 Protestant Denominations

 Other _______________

8. Education level:  Did not complete High School

 High School Diploma/GED

 Some College/Vocational School

 Bachelor’s Degree

 Advanced Degree

9. Current employment status:  Full-time

 Part-time

 Working at home (child care, sewing, etc.)

 Not working, but looking for a job

 Not working by choice (homemaker, retired)

 Unable to work

Current occupation: ____________________________________________

Thinking of everyone who lives in your home, what is the total monthly income in your home?

 Less than $1,000  $7,000 - $7,999

 $1,000 - $1,999  $8,000 - $8,999

 $2,000 - $2,999  $9,000 - $9,999

 $3,000 - $3,999  $10,000 - $10,999

 $4,000 - $4,999  $11,000 - $11,999

 $5,000 - $5,999  $12,000 - $12,999

 $6,000 - $6,999  $13,000 or more

Public reporting burden for this collection of information is estimated to average 2 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0590). Do not return the completed form to this address.