Sample Demographic Survey

Form Approved

OMB No. 0920-XXXX

Exp. Date XX/XX/XXXX

Attachment 3c Sample Demographic Survey

Using Rapid Assessment Methods to Understand Issues in

HIV Prevention, Care and Treatment in the United States

Public reporting burden of this collection of information is estimated to average 15 minutes 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 CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-New)

1. Brief Response

INTERVIEWER READ INTRODUCTION: I am going to ask you several quick questions to get a better background understanding of you and your situation. Please answer openly and to the best of your abilities. Remember that you can refuse or skip any question you don’t wish to answer.

1. How old are you?

   1. Under 18 years old STOP INTERVIEW

   2. 18 – 25 years old

   3. 26 – 35 years old

   4. 36 years and over

2. Do you think of yourself as:

   1. Gay

   2. Straight, that is, not gay

   3. Bisexual

   4. Something else

   5. Don’t know/Questioning

3. Are you Hispanic, Latino/a, or Spanish origin?

   1. Yes

   2. No

   3. Refused

4. What is your race? You may choose more than one category.

   1. American Indian or Alaska Native

   2. Asian

   3. Black or African American

   4. Native Hawaiian or Other Pacific Islander

   5. White

   6. REFUSED

5. In what country or territory were you born? [DON’T READ CHOICES. CIRCLE ONE.]

1. United States

2. Other (Specify: _________________________________________)

3. Refused

4. Don’t know

6. What is the highest level of education you completed?

1. Never attended school

2. Grades 1 through 8

3. Grades 9 through 11

4. High School diploma or GED

5. Some college, associate’s degree, or technical degree

6. Bachelor’s Degree

7. Any post-graduate studies

8. Refused

9. Don’t know

6. During the past 12 months, have you had any kind of health insurance or health coverage? This includes Medicaid and Medicare.

   1. Yes

   2. No SKIP TO A9

   3. Refused

   4. Don’t know

6. During the past 12 months, was there a time that you didn’t have any health insurance or health coverage?

   1. Yes

   2. No

   3. Refused

   4. Don’t know

6. Are you currently…?

   1. Employed for wages

   2. Self-employed

   3. Out of work for more than 1 year

   4. Out of work for less than 1 year

   5. A Homemaker

   6. A Student

   7. Retired

   8. Unable to work

   9. Something else (SPECIFY)

   10. Refused

6. In 2013, what was your total combined yearly household income from all sources before taxes? “Total combined household income” means the total amount of money from all people living in the household. (INTERVIEWER: Clarify range if not clear in response)

1. $ 0 to $25,000

2. Over $25,000 but under $50,000

3. $50,000 or over but under $75,000

4. $75,000 or over

5. Refused

6. Don’t know

6. Do you currently receive any of form of public assistance?

   1. Yes -- What is it? ______________

   2. No

   3. Don’t Know/ Don’t Remember

6. [ASK FOR SPANISH ONLY] The rest of this interview is all in Spanish, but for classification purposes we need to ask: how well you speak English? Would you say....

   1. Very well

   2. Well

   3. Not well

   4. Not at all

   5. Refused

   6. Don’t know

6. In the past 12 months have you stayed on the street, in a shelter, or temporarily in someone's home because you had no regular place to live or stay?

   1. Yes

   2. No

   3. REFUSED

   4. DON’T KNOW

6. Who lives in your household? Please tell me by giving their relationship to you rather than their name like ‘my grandmother’ not her name. [INTERVIEW: Note descriptors for use in IDI]

Descriptor 1____________________

Descriptor 2____________________

Descriptor 3 _____________________

Descriptor 4 _____________________

Additional Descriptors _________________________________________

COUNT_______