Form #1 Form #1 Demographic Questionnaire

A

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

ttachment H: Demographic Questionnaire

1. What is your gender?

• Male

• Female

2. What is your age?

• 19 – 24

• 25 – 39

• 40 – 49

• 50 – 64

• 65+

3. Do you consider yourself to be Latino(a), Hispanic, or of Spanish origin or descent?

• Yes

• No

4. Which one or more of the following would you say is your race?

• White/Caucasian

• Black/African American

• Asian

• Native Hawaiian or Other Pacific Islander

• American Indian or Alaska Native

• Other:

• Don’t know

• Refused

5. What is your marital status?

• Married

• Divorced

• Widowed

• Separated

• Never married

• A member of an unmarried couple

• Refused

Public reporting burden for this collection of information is estimated to average 5 minutes per response, the estimated time required to complete the survey. 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: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

6. What is the highest grade or year of school you completed?

• Never attended school or only attended kindergarten

• Grades 1 through 8 (Elementary)

• Grades 9 through 11 (Some high school)

• Grade 12 or GED (High school graduate)

• College 1 year to 3 years (Some college or technical school)

• College 4 years or more (College graduate)

• Refused