Att 4-DemographicQuestions

Att 4-DemographicQuestions.docx

CDC and ATSDR Health Message Testing System

Att 4-DemographicQuestions

OMB: 0920-0572

Document [docx]
Download: docx | pdf

Attachment 4: Demographic Questions

Demographic Questions


Form Approved

OMB No. 0920-0572

Expiration Date: xx-xx-xxxx

A. Demographic Questions

(Questions can be used for Central Location Intercept Interviews, Telephone Interviews, Individual In-depth Interviews [Cognitive Interviews], Focus Group Screeners, and Focus Groups.)


  1. Gender:

  • Male

  • Female


  1. In which of the following categories does your age fall:

  • under 18 years of age

  • 18-24 years of age

  • 25-34 years of age

  • 35-44 years of age

  • 45-54 years of age

  • 55-64 years of age

  • 65-74 years of age

  • 75 years of age or older


  1. In what year were you born?

  • _________ [RECORD YEAR OF BIRTH]

  • Don’t Know/Not Sure (DO NOT READ)

  • Refused (DO NOT READ)


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

  • Grade school

  • Less than high school graduate/some high school

  • High school graduate or completed GED

  • Some college or technical school

  • Received four-year college degree

  • Some post graduate studies

  • Received advanced degree

  • Other: _____________________


  1. Please tell me your race or ethnic background. Do you consider yourself?

Ethnicity:

  • Hispanic or Latino

  • Not Hispanic or Latino

  • Don’t Know/Not Sure (DO NOT READ)

  • Refused (DO NOT READ)


Race:

  • White/Caucasian

  • Black or African-American

  • American Indian or Alaska Native

  • Native Hawaiian or Other Pacific Islander

  • Asian

  • Vietnamese

  • Cambodian

  • Filipino

  • Japanese

  • Korean

  • Chinese

  • Don’t Know/Not Sure (DO NOT READ)

  • Refused (DO NOT READ)


  1. Please indicate your race or ethnic background. Are you?

Ethnicity:

  1. Hispanic or Latino

  2. Not Hispanic or Latino


Race: SELECT ONE OR MORE.

  1. White/Caucasian

  2. Black or African-American

  3. American Indian or Alaska Native

  4. Native Hawaiian or Other Pacific Islander

  5. Asian

6 Vietnamese

7 Cambodian

8 Filipino

9 Japanese

10 Korean

11 Chinese


  1. Were you born in the United States?

  • Yes

  • No


  1. In what state, city, and zip code do you currently live?


  1. In what state, city, and zip code do you currently live? ENTER FIVE DIGIT ZIP CODE.










  1. What is your current occupational status? Would you say…?

  • Employed full time

  • Employed part time

  • Unemployed

  • Homemaker

  • Student

  • Retired, or

  • Disabled

  • Other:_______________

  • Don’t Know/Not Sure (DO NOT READ)

  • Refused (DO NOT READ)


  1. What is your current job title? What term would you use to describe your current profession?


_____________________________________________________________________


  1. What is your marital status?

  • Married

  • Unmarried living with a partner

  • Divorced

  • Widowed

  • Separated, or

  • Single, never been married

  • Don’t Know/Not Sure (DO NOT READ)

  • Refused (DO NOT READ)


  1. Which of the following categories best describe your total, annual household income?

  • Under $20,000/year

  • $20,001 - $30,000/year

  • $30,001 - $40,000/year

  • $40,001 - $50,000/year

  • $50,001 - $60,000/year

  • $60,001 - $80,000/year

  • $80,001 - $100,000/year

  • Over $100,000/year


  1. Number of children (under age 18) living in the household:

  • None

  • 1-2 children

  • 3-4 children

  • 5 or more children


  1. Do you currently rent or own your home?

  • Own

  • Rent

  • Occupied without paying monetary rent


  1. What is your current relationship status? Are you…?

  • Single

  • Married to a man

  • Married to a woman

  • In a relationship with a man

  • In a relationship with a woman

  • Divorced or Widowed

  • Refused




  1. Have you ever had an HIV test?

  • Yes

  • No


  1. What was the result of your last HIV test?

  • Positive

  • Negative

  • Don’t know


  1. When was the last time you had an HIV test?

__________________________ (Record Date)


  1. Now I am going to ask you to describe your sexual identity. Would you describe yourself as:

  • Homosexual or “gay” or same gender loving

  • Bisexual or two spirited

  • Other, specify____________________________________

  • Heterosexual or “straight”

  • Don’t know

  • Decline to answer


  1. Within the past 6 months, who have you primarily had sex with?

  • A male

  • A female

  • Haven’t had sex in the last 6 months

  • Refused


  1. Within the past 6 months, have you had unprotected sex? By “unprotected sex” we mean having sex without a condom.

  • Yes

  • No

  • Refused


  1. Within the past 6 months, have you had sex with more than one partner?

  • Yes

  • No


  1. Are you the parent or guardian of a [boy/girl], ages [INSERT range] years?

  • Yes

  • No


  1. What is your age? ___________________ (record age)


  1. Are you or have you ever been sexually active?

  • Yes

  • No


  1. Do you feel comfortable reading materials that require a 7th grade reading level?

  • Yes

  • No


  1. What is your job title or role?

  • [Public Health Professional: e.g. epidemiologist, health communicator, health educator, etc]

  • [Healthcare Provider: e.g. doctor (MD, DO), nurse, nurse practitioner, physician’s assistant]

  • [General Consumer: neither a Public Health Professional nor a Healthcare Provider]

  • [Other:___________]




  1. Describe your work environment:

  • Hospital

  • Emergency room

  • Clinic

  • Office

  • Field

  • Academic

  • Research

  • Home or telecommute

  • [Other:___________]


  1. What is your primary specialty?

  • Family Medicine

  • Internal Medicine

  • Obstetrics/Gynecology

  • Oncology

  • Pathology

  • Psychiatry

  • Clinical Genetics

  • Other (please specify): ________________________________________


  1. Do you have a subspecialty?

  • Yes (If Yes, please specify, i.e. pediatric oncology, gynecologic oncology, etc.): ________________

  • No


  1. Have you smoked at least 100 cigarettes in your entire life? SINGLE RESPONSE.

  • Yes

  • No


  1. Do you now smoke cigarettes every day, some days, or not at all? SINGLE RESPONSE.

  • Every day

  • Some days

  • Not at all


  1. During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking? SINGLE RESPONSE.

  • Yes

  • No


  1. About how long has it been since you completely quit smoking cigarettes? FILL IN NUMBER FOR UNIT THAT APPLIES.

_____ Days

_____ Weeks

_____ Months

_____ Years


  1. On how many of the past 30 days did you smoke cigarettes?


Enter number: _______


  1. On the average, on those (INSERT QUESTION #36a RESPONSE) days, how many cigarettes did you usually smoke each day?


FILL IN NUMBER ______





  1. Which of these best describes the area in which you work most of the time?

  • Mainly work indoors

  • Mainly work outdoors

  • Travel to different buildings or sites

  • In a motor vehicle, or

  • Somewhere else

  • Varies


  1. On a scale from 1 to 5, where 1 indicates that you strongly disagree, and 5 indicates that you strongly agree, please tell me the number which indicates how much you agree or disagree with the following statement:

Strongly Disagree Strongly Agree

I rely on my doctor to tell me everything 1 2 3 4 5

I need to know to manage my health 1 2 3 4 5


  1. Which of the following actions do you currently do, if any?

  • Buy environmentally-friendly products

  • Buy products that use less packaging

  • Use less energy at home (lights, AC, heat)

  • Buy energy-efficient appliances (i.e.: light bulbs)/insulation

  • Buy products made from recycled paper/plastic

  • Recycle at home

  • Punish companies with bad environmental records by not buying their products


  1. Which of the following describes the number of friends and acquaintances you regularly keep in touch with?

  • Less than 10

  • 10 or more

  • 25 - 44

  • 45 or more


  1. Most of the discussion will involve speaking and reading in English. Are you comfortable with speaking and reading in English?


  1. Did you have [disease/health condition] diagnosed by [sign, symptom, or test]?


  1. Do you have [disease or condition]?


  1. For how long have you had [disease or condition]?


  1. Have you been diagnosed with [disease or condition] in the past [#] year(s)?


  1. When were you diagnosed?


  1. Did you receive treatment for your [disease or condition]?


  1. Do you experience or are you still experiencing symptoms of [disease or condition]?


  1. What type of symptoms do you experience (or are you still experiencing)?


  1. Before [most recent episode/diagnosis/case/symptom expression/experience/exposure], had you ever been diagnosed with [disease or condition]?


  1. Do you ever use the Internet for health information?


  1. Where did you hear about this project?


  1. Are you related to anyone already participating in this project?


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title Demographic
AuthorAngela Ryan
File Modified0000-00-00
File Created2021-01-25

© 2024 OMB.report | Privacy Policy