Demographic Information Sheet

Demographic Information Sheet

1. AGE: ____________________

2. GENDER: ________________

3. Which of the following best describes you? You may pick more than one. READ CATEGORIES.

RACE:

1. White/Caucasian

2. Black or African-American

3. American Indian or Alaska Native

4. Native Hawaiian or other Pacific Islander

5. Asian

6. Refuse to answer

ETHNICITY:

1. Hispanic or Latino

2. Not of Hispanic or Latino Origin

3. Refused

4. EMPLOYMENT STATUS ( please circle the answer that best describes you):

1. Employed full-time

2. Employed part-time

3. Not currently employed

4. Retired

5. Student

5. What type of SCD have you been diagnosed with? _____________________________

6. Do you receive care at a Comprehensive SCD Center( please circle the answer that best describes you?

1. Yes

2. No