BIRCH Attachment I (redlined change)

BIRCH Changes to Attachment I Demographic Survey 5-12-2022.docx

Formative Research on Community-Level Factors that Promote the Primary Prevention of Adverse Childhood Experiences (ACEs) and Opioid Misuse Among Children, Youth, and Families in Tribal American India

BIRCH Attachment I (redlined change)

OMB: 0920-1351

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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.

  1. 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


Revised 7)

What is the gender identity you best identify with?

  • ______________________________

  • 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

  • Hispanic or Latino

  • 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

Revised 9)

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


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 the name of tribe.

  • List:___________________________


Revised 11)

What tribe(s) do you identify with? List names of tribe(s).

  • List: __________________________

  • Prefer not to answer


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



Revised 15)

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



Revised

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



Revised

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


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AuthorErica Roberts
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