Demographic Questions
Form Approved
OMB No. 0920-0572
Expiration Date: xx-xx-xxxx
(Questions can be used for Central Location Intercept Interviews, Telephone Interviews, Individual In-depth Interviews [Cognitive Interviews], Focus Group Screeners, and Focus Groups.)
Gender:
Male
Female
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
In what year were you born?
_________ [RECORD YEAR OF BIRTH]
Don’t Know/Not Sure (DO NOT READ)
Refused (DO NOT READ)
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: _____________________
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)
Please indicate your race or ethnic background. Are you?
Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Race: SELECT ONE OR MORE.
White/Caucasian
Black or African-American
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Asian
6 Vietnamese
7 Cambodian
8 Filipino
9 Japanese
10 Korean
11 Chinese
Were you born in the United States?
Yes
No
In what state, city, and zip code do you currently live?
In what state, city, and zip code do you currently live? ENTER FIVE DIGIT ZIP CODE.
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)
What is your current job title? What term would you use to describe your current profession?
_____________________________________________________________________
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)
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
Number of children (under age 18) living in the household:
None
1-2 children
3-4 children
5 or more children
Do you currently rent or own your home?
Own
Rent
Occupied without paying monetary rent
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
Have you ever had an HIV test?
Yes
No
What was the result of your last HIV test?
Positive
Negative
Don’t know
When was the last time you had an HIV test?
__________________________ (Record Date)
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
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
Within the past 6 months, have you had unprotected sex? By “unprotected sex” we mean having sex without a condom.
Yes
No
Refused
Within the past 6 months, have you had sex with more than one partner?
Yes
No
Are you the parent or guardian of a [boy/girl], ages [INSERT range] years?
Yes
No
What is your age? ___________________ (record age)
Are you or have you ever been sexually active?
Yes
No
Do you feel comfortable reading materials that require a 7th grade reading level?
Yes
No
[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:___________]
Describe your work environment:
Hospital
Emergency room
Clinic
Office
Field
Academic
Research
Home or telecommute
[Other:___________]
What is your primary specialty?
Family Medicine
Internal Medicine
Obstetrics/Gynecology
Oncology
Pathology
Psychiatry
Clinical Genetics
Other (please specify): ________________________________________
Do you have a subspecialty?
Yes (If Yes, please specify, i.e. pediatric oncology, gynecologic oncology, etc.): ________________
No
Have you smoked at least 100 cigarettes in your entire life? SINGLE RESPONSE.
Yes
No
Do you now smoke cigarettes every day, some days, or not at all? SINGLE RESPONSE.
Every day
Some days
Not at all
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
About how long has it been since you completely quit smoking cigarettes? FILL IN NUMBER FOR UNIT THAT APPLIES.
_____ Days
_____ Weeks
_____ Months
_____ Years
On how many of the past 30 days did you smoke cigarettes?
Enter number: _______
On the average, on those (INSERT QUESTION #36a RESPONSE) days, how many cigarettes did you usually smoke each day?
FILL IN NUMBER ______
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
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
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
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
Most of the discussion will involve speaking and reading in English. Are you comfortable with speaking and reading in English?
Did you have [disease/health condition] diagnosed by [sign, symptom, or test]?
Do you have [disease or condition]?
For how long have you had [disease or condition]?
Have you been diagnosed with [disease or condition] in the past [#] year(s)?
When were you diagnosed?
Did you receive treatment for your [disease or condition]?
Do you experience or are you still experiencing symptoms of [disease or condition]?
What type of symptoms do you experience (or are you still experiencing)?
Before [most recent episode/diagnosis/case/symptom expression/experience/exposure], had you ever been diagnosed with [disease or condition]?
Do you ever use the Internet for health information?
Where did you hear about this project?
Are you related to anyone already participating in this project?
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Demographic |
| Author | Angela Ryan |
| File Modified | 0000-00-00 |
| File Created | 2021-01-25 |