3 Cog Testing - Demographics Questionnaire

Participant #________________

Demographic Information

1. In what month and year were you born? _________________ __________________

month year

2. What is the highest grade or year of school you have completed?

Less than high school

Completed high school

Some college, no degree (indicate area of study: ____________________________________)

Associate’s degree (AA/AS) (indicate area of study: __________________________________)

Bachelor’s Degree (BA/BS) (indicate area of study: __________________________________)

Post-Bach degree (indicate degree and area of study: ________________________________)

3. Are you male or female?

Male

Female

4. Are you of Hispanic, Latino, or Spanish origin?

Yes

No

5. What is your race? Choose one or more races.

White

Black or African American

American Indian or Alaska Native

Asian

Native Hawaiian or Other Pacific Islander