Form 1 Demographics Questionnaire

Generic Clearance for Questionnaire Pretesting Research

Enclosure 3 original demographic questionnaire

CEDSCI Usability Evaluation Addendum

OMB: 0607-0725

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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?

Shape1 Less than high school

Shape2 Completed high school

Shape3 Some college, no degree (indicate area of study: ____________________________________)

Shape4 Associate’s degree (AA/AS) (indicate area of study: __________________________________)

Shape5 Bachelor’s Degree (BA/BS) (indicate area of study: __________________________________)

Shape6 Post-Bach degree (indicate degree and area of study: ________________________________)


3. Are you male or female?

Shape7 Male

Shape8 Female


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

Shape9 Yes

Shape10 No


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

Shape11 White

Shape12 Black or African American

Shape13 American Indian or Alaska Native

Shape14 Asian

Shape15 Native Hawaiian or Other Pacific Islander





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