Crosswalk Template to Non-Substantive Change (Att I)

Form	Current Question/Item	Requested Change
Attachment I. Demographic Survey Item 2)	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	Delete item
Attachment I. Demographic Survey Item 3a)	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	Delete item
Attachment I. Demographic Survey Item 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	Delete item
Attachment I. Demographic Survey Item 4)	How many people (adults and children under the age of 18) currently live in your household? [Write number] ___ ______ • Prefer not to answer	Delete item
Attachment I. Demographic Survey Item 6)	What sex were you assigned at birth, on your original birth certificate? • Female • Male • I don’t know • Prefer not to answer	Delete item
Attachment I. Demographic Survey Item 7)	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	What is the gender identity you best identify with? ___________________________________________________________ • Prefer not to answer
Attachment I. Demographic Survey Item 8)	Which of the following options best describes your ethnicity? • Hispanic or Latino • Not Hispanic or Latino • I don’t know • Prefer not to answer	Delete item
Attachment I. Demographic Survey Item 9)	Which categories or category best describe your race? Check all that apply. • American Indian or Alaska Native • Asian • Black or African American • Hispanic or Latino • Native Hawaiian or Other Pacific Islander • White • I don’t know • Prefer not to answer	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
Attachment I. Demographic Survey Item 10)	How many tribal nations do you identify with? • One tribe • Two tribes • Three or more tribes • I don’t know • Prefer not to answer	Delete item
Attachment I. Demographic Survey Item 11	Which is the main tribe you identify with? List the name of tribe. List_______________________________________________	Which tribe(s) do you identify with? List names of tribe(s). List _______________________________________________________ • Prefer not to answer
Attachment I. Item 12)	Which is the second tribe you identify with? List name of tribe. List_______________________________________________	Delete item
Attachment I. Item 13)	Are you enrolled in any tribal nation? • Yes • No • I don’t know • Prefer not to answer	Delete item
Attachment I. Item 14)	In which tribal nation are you enrolled? List name of tribal nation. List _____________________________________________	Delete item
Attachment I. Item 15)	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	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 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 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