Form 0920-20PJ Demographic Survey

Attachment I. Demographic Survey

Form Approved

OMB No: 0920-xxxx
Exp. Date: xx-xx-xxxx

Public Reporting burden of this collection of information is estimated at 25 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 NW, MS D-74, Atlanta, GA  30333; Attn:  PRA (0920-xxxx).

Site ID: _ _ _ _ _

Thank you for agreeing to participate in this study on how AI/AN communities support health and well-being. Before we begin the conversation, we ask that you complete this survey. The information we collect in this survey will help us learn more about the people who participated in the study. The survey asks that you provide some information about yourself and your experiences. This information will be used to describe characteristics of participants. For example, from this survey we would know and will be able to report the age range for participants. We know this information is personal and private. Your answers will be kept confidential to the best of our ability. The responses that you provide will not be shared or used for any purposes other than to provide demographic information about the participants who take part in this study. You will notice that we are not asking for your name as part of the survey. When we report on the survey, we will not use your name in any way. Your responses to the survey will be stored separately from your responses in a secure location only accessible by the study team. You can choose to skip or not answer any question for any reason. You can also decide to not complete this survey and still participate in the discussion today.

Personal Information
	What year were you born?	___ ___ ___ ___ I don’t know Prefer not to answer
	What is the highest level of education you have completed?	No formal education Grade school High school or equivalent 2-year junior or community college Vocational, business, or trade school 4-year college or university Graduate or professional school I don’t know Prefer not to answer
3a)	What is your best estimate of your household’s current total annual income from all sources before taxes? (Include money from jobs, social security, retirement income, per capita payments, unemployment payments, public or tribal assistance such as housing supplements and so forth. Also include income from interest, dividends, net income from business, farm, or rent and any other money income).	[Write amount] $________________ I don’t know Prefer not to answer	If you wrote in an amount, please skip to question 4).
3b)	If you responded to item 3a with “I don’t know” or “Prefer not to answer,” please indicate the range that best estimates your household’s total annual income.	Less than $20,000 $20,001 to $30,000 $30,001 to $40,000 $40,001 to 50,000 $50,001 to $60,000 $60,001 to $70,000 $70,001 to $80,000 $80,001 to $90,000 $90,001 to $100,000 $100,000 to $135,000 Higher than $135,000 I don’t know Prefer not to answer
	How many people (adults and children under the age of 18) currently live in your household?	[Write number]___ ______ Prefer not to answer
	If you have children living in your home who attend childcare or school, is your household eligible for free or reduced lunch?	Yes No I don’t know Prefer not to answer N/A
	What sex were you assigned at birth, on your original birth certificate?	Female Male I don’t know Prefer not to answer
	Do you currently describe yourself as male, female, or transgender?	Male Female Transgender Two-spirit or other tribally- or culturally-specific term Other I don’t know Prefer not to answer
	Which of the following options best describes your ethnicity?	Hispanic or Latino Not Hispanic or Latino I don’t know Prefer not to answer
	Which categories or category best describe your race? Check all that apply.	American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White I don’t know Prefer not to answer	If you DID NOT select American Indian or Alaska Native, please skip to question 15
	How many tribal nations do you identify with?	One tribe Two tribes Three or more tribes I don’t know Prefer not to answer
	Which is the main tribe you identify with? List name of tribe.	List: ________________
	Which is the second tribe you identify with? List name of tribe.	List: ________________	Answer only if you selected Two tribes or Three Tribes in question 10
	Are you enrolled in any tribal nation?	Yes No I don’t know Prefer not to answer
	In which tribal nation are you enrolled? List name of tribal nation.	List: ____________	Answer only if you selected Yes in question 13
	Would you say your health is excellent, very good, good, fair, or poor?	Excellent Very good Good Fair Poor I don’t know Prefer not to answer

Thank You