Attachment 5 - Demographics - Clean Copy - 2.28.2025

• Demographic Questions

1. Demographic Questions

Form Approved OMB No. 0920-0572

Expiration Date: xx-xx-xxxx

(Questions can be used for Central Location Intercept Interviews, Telephone Interviews, Individual In-depth Interviews [Cognitive Interviews], Focus Group Screeners, and Focus Groups.)

1a. Are you …?

• Female

• Male

2a. In which of the following categories does your age fall:

• under 18 years of age

• 18-24 years of age

• 25-34 years of age

• 35-44 years of age

• 45-54 years of age

• 55-64 years of age

• 65-74 years of age

• 75 years of age or older

3a. What is your age? (record age)

4a. In what year were you born?

• [RECORD YEAR OF BIRTH]

• Prefer not to answer

5a. What is the highest level of education you have completed?

• Grade school

• Less than high school graduate/some high school

• High school graduate or completed GED

• Some college or technical school

• Received four-year college degree

• Some post graduate studies

• Received advanced degree

• Other:

6a. What is your race/ethnicity?

Select all that apply and enter additional details in the spaces below.

□ American Indian or Alaska Native Enter, for example, Navajo Nation, Blackfeet Tribe of the Blackfeet Indian Reservation of Montana, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community, Aztec, Maya, etc.

□ Asian - Provides details below

□ Chinese □ Asian Indian □ Filipino

□ Vietnamese □ Korean □ Japanese

Enter for example, Pakistani, Hmong, Afghan

□ Black or African American – Provide details below

□ African American □ Jamaican □ Haitian

□ Nigerian □ Ethiopian □ Somali

Enter for example, Pakistani, Hmong, Afghan

□ Hispanic or Latino – Provide details below

□ Mexican □ Puerto Rican □ Salvadoran □ Cuba

□ Dominican □ Guatemalan

Enter for example, Colombian, Honduran, Spaniar

□ Middle Eastern or North African – Provide details below

□ Lebanese □ Iranian □ Egyptian □ Syria

□ Iraqi □ Israeli

Enter for example, Moroccan, Yemeni, Kurdish

□ Native Hawaiian or Pacific Islander – Provide details below

□ Native Hawaiian □ Samoan □ Chamorro □ Tongan □Fijian □ Marshallese

Enter for example, Chuukese, Palauan, Tahitian

□ White – Provide details below

□ English □ German □ Irish □ Italian □ Polish □ Scottish

Enter for example, French, Swedish, Norwegian

7a. Were you born in the United States?

• Yes

• No

8a. In what state do you live? DROP DOWN LIST OF 50 STATES AND DC

9a. In what state, city, and zip code do you currently live? ENTER FIVE DIGIT ZIP CODE.

10a. What is your current occupational status? Would you say…?

• Employed full time

• Employed part time

• Unemployed

• Homemaker

• Stay-at-home parent

• Student

• Retired, or

• Disabled

• Other:

• Prefer not to answer

11a. What is your current job title? What term would you use to describe your current profession?

12a. What is your marital status?

• Married

• Unmarried living with a partner

• Divorced

• Widowed

• Separated

• Single, never been married

• Prefer not to answer

13a. Which of the following categories best describe your total, annual household income?

• Under $20,000/year

• $20,001 - $30,000/year

• $30,001 - $40,000/year

• $40,001 - $50,000/year

• $50,001 - $60,000/year

• $60,001 - $80,000/year

• $80,001 - $100,000/year

• Over $100,000/year

• Prefer not to answer

14a. Are you the parent or main/primary caregiver responsible for at least one child under the age of 18?

• Yes

• No

15a. Number of children (under age 18) living in the household:

• None

• 1-2 children

• 3-4 children

• 5 or more children

16a. Do you currently rent or own your home?

• Yes, I own my home

• Yes, I rent my home

• No, I live in a home but do not own or rent it

17a. Do you feel comfortable reading materials that require a 7th grade reading level?

• Yes

• No

18a. What is your job title or role?

• [Public Health Professional: e.g. epidemiologist, health communicator, health educator, etc]

• [Healthcare Provider: e.g. doctor (MD, DO), nurse, nurse practitioner, physician’s assistant]

• [General Consumer: neither a Public Health Professional nor a Healthcare Provider]

• [Other: ]

19a. Describe your work environment:

• Hospital

• Emergency room

• Clinic

• Office

• Field

• Academic

• Research

• Telework or Remote

• [Other: ]

20a. What is your primary specialty?

• Family Medicine

• Internal Medicine

• Obstetrics/Gynecology

• Oncology

• Pathology

• Psychiatry

• Clinical Genetics

• Other (please specify):

21a. Do you have a subspecialty?

• Yes (If Yes, please specify, i.e. pediatric oncology, gynecologic oncology, etc.):

• No

22a. Which of these best describes the area in which you work most of the time?

• Mainly work indoors

• Mainly work outdoors

• Travel to different buildings or sites

• In a motor vehicle, or

• Somewhere else

• Varies

23a. On a scale from 1 to 5, where 1 indicates that you strongly disagree, and 5 indicates that you strongly agree, please tell me the number which indicates how much you agree or disagree with the following statement:

	Strongly Disagree				Strongly Agree
I rely on my doctor to tell me everything	1	2	3	4	5
I need to know to manage my health	1	2	3	4	5

24a. Which of the following actions do you currently do, if any?

• Buy environmentally-friendly products

• Buy products that use less packaging

• Use less energy at home (lights, AC, heat)

• Buy energy-efficient appliances (i.e.: light bulbs)/insulation

• Buy products made from recycled paper/plastic

• Recycle at home

• Punish companies with bad environmental records by not buying their products

25a. Which of the following describes the number of friends and acquaintances you regularly keep in touch with?

• Less than 10

• 10 or more

• 25 - 44

• 45 or more

26a. Most of the discussion will involve speaking and reading in English. Are you comfortable with speaking and reading in English?

27a. Did you have [disease/health condition] diagnosed by [sign, symptom, or test]?

28a. Do you have [disease or condition]?

29a. For how long have you had [disease or condition]?

30a. Have you been diagnosed with [disease or condition] in the past [#] year(s)?

31a. When were you diagnosed?

32a. Did you receive treatment for your [disease or condition]?

33a. Do you experience or are you still experiencing symptoms of [disease or condition]?

34a. What type of symptoms do you experience (or are you still experiencing)?

35a. Before [most recent episode/diagnosis/case/symptom expression/experience/exposure], had you ever been diagnosed with [disease or condition]?

36a. Do you ever use the Internet for health information?

37a. Where did you hear about this project?

38a. Are you related to anyone already participating in this project?