23 survey

ID NUMBER:

FORM CODE: PIE VERSION: A 7/02/07

Contact Occasion

SEQ #

OMB#: 0925-0584

Exp. XX/XXXX

Public reporting burden for this collection of information is estimated to average 09 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0584). Do not return the completed form to this address.

H

OMB#: 0925-0584

Exp. XX/XXXX

CHS/SOL Personal Information Questionnaire

ID NUMBER:

FORM CODE: PIE VERSION: A 11/21/08

Contact Occasion

SEQ #

Acrostic:

Administrative Information

0a. Completion Date: // 0b. Staff ID:

Month Day Year

Instructions: Enter the answer given by the participant for each response. The special value, "Q", is allowed for cases where the response 'Don’t know/refused' is not listed as an option. Use location codes at end for coding place of birth.

A. Demographics

1. Gender: Male 1 Female 2

2. Date of Birth: //19

Month Day Year

3. Marital Status: (Mark only one)

Single 1

Married 2

Separated 3

Divorced 4

Widow(er) 5

Living with a partner 6

4. In what country or territory were you born? (Select location code from list)

5. Which of the following best describes your Hispanic/Latino heritage? (Mark only one)

Dominican or Dominican descent 0

Central American or Central American descent 1

Cuban or Cuban descent 2

Mexican or Mexican descent 3

Puerto - Rican or Puerto Rican descent 4

South American or South American descent 5

More than one heritage 6

Other 7

If other, please specify: __________________

6. In addition to being of Hispanic/Latino heritage, which of the following categories would you use to describe yourself? (Mark only one)

American Indian or Alaskan Native 1

Asian 2

Native Hawaiian or Other Pacific Islander 3

Black or African – American 4

White 5

More than one race 6

Unknown or Not reported 7

IF RESPONSE TO QUESTION 4 IS U.S. BORN (63),  GO TO QUESTION 11

B. Residential History

7. From the time that you FIRST moved to the U.S. to today, about how many years have you lived in the mainland U.S. (50 states + DC)? (Round to the nearest full year)

Number of years

8. When you are in the United States, do you live in the same state all year?

No 0

Yes 1

9. Except for short vacations, do you return to your native country for part of each year?

No 0  GO TO QUESTION 11

Yes 1

10. How many months per year? Months per year

C. Parents/Grandparents

11. Where was your mother born? (Select location code from list)

12. Where was your maternal grandmother born? (Select location code from list)

13. Where was your maternal grandfather born? (Select location code from list)

14. Where was your father born? (Select location code from list)

15. Where was your paternal grandmother born? (Select location code from list)

16. Where was your paternal grandfather born? (Select location code from list)

D. Education

17. How many years of schooling in total have you completed?

Years

If response to Question 17 equals “0”  GO TO QUESTION 22

18. In what country or territory was your highest level of education completed? (Select location code from list)

19. What was the highest grade/level of education achieved? If exact level is not listed, mark the closest equivalent. (Mark only one)

Elementary/primary school (includes grades 1 – 5) 1

Middle school/junior high (includes grades 6 – 8) 2

High School/preparatory school 3

Trade school/vocational school 4

University/college 5

Other 6

If other, please specify:_________________________

20. Have you received any diplomas, certificates or degrees from your schooling?

No 0  GO TO QUESTION 22

Yes 1

21. What types of diploma, certificate, or degree did you receive? If exact diploma, certificate, or degree is not listed, mark the closest equivalent.

No Yes

a. High School diploma or equivalent (includes GED) 0 1

b. Trade school/vocational school certificate 0 1

c. Associate degree (i.e. AA, AS) 0 1

d. Bachelor’s degree (i.e. BA, AB, BS) 0 1

e. Master’s degree (i.e. MA, MS, MEd, MSW, MBA) 0 1

f. Professional degree (i.e. MD, DDS, DVM, LLB, JD) 0 1

g. Doctorate degree (i.e. PhD, EdD) 0 1

h. Other 0 1

If other, please specify:_________________________

22. What was the highest grade/level of education achieved by your father? (Mark only one)

No schooling 1

Elementary/primary school (includes grades 1 – 5) 2

Middle school/junior high (includes grades 6 – 8) 3

High School/preparatory school 4

Trade school/vocational school 5

University/college 6

Other 7

If other, please specify:_________________________

23. What was the highest grade/level of education achieved by your mother? (Mark only one)

No schooling 1

Elementary/primary school (includes grades 1 – 5) 2

Middle school/junior high (includes grades 6 – 8) 3

High School/preparatory school 4

Trade school/vocational school 5

University/college 6

Other 7

If other, please specify:_________________________

Location Codes for Question 4, 11, 12, 13, 14, 15, 16, and 18

1. Afghanistan

2. Anguilla

3. Antigua and Barbuda

4. Argentina

5. Aruba

6. Australia

7. Austria

8. Bangladesh

9. Belgium

10. Belize

11. Bolivia

12. Brazil

13. Canada

14. Chile

15. China

16. Colombia

17. Costa Rica

18. Cuba

19. Czech Republic

20. Denmark

21. Dominican Republic

22. Ecuador

23. El Salvador

24. Finland

25. France

26. Germany

27. Great Britain

28. Greece

29. Guam

30. Guatemala

31. Haiti

32. Holland

33. Honduras

34. Hungary

35. India

36. Indonesia

37. Iran

38. Iraq

39. Ireland

40. Israel

41. Italy

42. Japan

43. Korea

44. Lebanon

45. Malaya

46. Mexico

47. New Zealand

48. Nicaragua

49. Norway

50. Pakistan

51. Panama

52. Paraguay

53. Peru

54. Philippines

55. Poland

56. Portugal

57. Puerto Rico

58. Russia

59. South Africa

60. Spain

61. Sweden

62. Switzerland

63. United States

64. Uruguay

65. Venezuela

66. Virgin Islands

67. Other

99 Unknown/refused

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