Form 0920-1351 Demographic Survey

Attachment I. Demographic Survey

Form Approved

OMB No: 0920-1351
Exp. Date: 10-31-2024

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 (0920-1351).

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
2)	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
3)	What is the gender identity you best identify with?	______________________________ Prefer not to answer
4)	In your own words, if you could describe your race or origin in any way you wanted, how would you describe yourself?	______________________________ Prefer not to answer
5)	In the last two weeks, would you say your physical health was excellent, very good, good, fair, or poor (in the way you understand it)?	Excellent Very good Good Fair Poor I don’t know Prefer not to answer
6)	In the last two weeks, would you say your emotional health was excellent, very good, good, fair, or poor?	Excellent Very good Good Fair Poor I don’t know Prefer not to answer
7)	In the last two weeks, would you say your cultural and spiritual health was excellent, very good, good, fair, or poor?	Excellent Very good Good Fair Poor I don’t know Prefer not to answer

Thank You