Form Approved
OMB No: 0920-1091
Exp. Date: 12/31/2018
Attachment 3b: Demographic Questionnaire Transgender Women
Participant ID:________ Data Collector ID:_______
Date:_________ Start time: __:__am/pm End time:__:__am/pm
Instructions: I am going to hand you a copy of this questionnaire to look at, but I will read each question out loud to you to answer. If there are any questions you would prefer not to answer, you can skip to the next. Remember that your participation is voluntary. These questions are being asked in order to provide context to the interviews.
What is your age in years? __________
What sex were you assigned at birth, on your original birth certificate? (Check one)
Male |
1 |
Female |
2 |
Refused to answer |
99 |
How do you describe your gender identity? (Check all that apply)
Male |
1 |
Female |
2 |
Male-to-female transgender (MTF) |
3 |
Female-to-male transgender (FTM) |
4 |
Other gender identity Please specify:_________________________________ |
5 |
Refused to answer |
99 |
Which of the following best represents how think of yourself? (Check one)
Gay (lesbian or gay) |
1 |
Straight, this is not gay (or lesbian or gay) |
2 |
Bisexual |
3 |
Something else Please specify:_________________________________ |
4 |
Refused to answer |
99 |
Do you consider yourself to be Hispanic or Latina? (Check one)
No, not Hispanic, Latina |
1 |
Yes, Mexican, Mexican American Chicana |
2 |
Yes, Puerto Rican |
3 |
Yes, Cuban |
4 |
Yes, Another Hispanic, Latina |
5 |
Refused to answer |
99 |
What is your race? You may choose more than one option category. (Check all that apply.)
American Indian or Alaska Native |
1 |
Asian |
2 |
Black or African-American |
3 |
Native Hawaiian or other Pacific Islander |
4 |
White |
5 |
Refused to answer |
99 |
What is the highest level of education you have completed? (Check one)
Never attended school |
1 |
Grades 1 through 8 |
2 |
Grades 9 through 11 |
3 |
Grades 12 or GED |
4 |
Some college, Associate’s Degree, or Technical Degree |
5 |
Bachelor’s Degree |
6 |
Any post graduate studies |
7 |
Refused to answer |
99 |
Don’t know |
77 |
How long have you been living in [insert city name]? ____________ years _________months
Public reporting burden of this collection of information is estimated to average 5 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 (0920-1901)
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Clarke Erickson |
| File Modified | 0000-00-00 |
| File Created | 2021-01-25 |