Form 1 Demographics

OMB #: 0925-NEW
Expiration Date: xx/xxxx

Public reporting burden for this collection of information is estimated to average 2 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-NEW). Do not
return the completed form to this address

Common Demographic Questions
Demographic Background Module
First, we are going to ask you some questions about yourself. Please remember that there are no right or wrong answers;
your honest answer is your best answer. If the question has a blank, fill in the blank. If the question has a list of choices,
please select the response that best reflects your answer.
D1.

What is your gender?
□ Male
□ Female

D2.
What is your current age?
years

D3a., D3b.
D3c.
D4.

D5a., D5b.

Which country do you live in?
code?

If US, which state do you live in?

Are you Hispanic or Latino?
□ Yes
□ No
□ Don’t know
Which one or more of the following would you say is your race?
□ Black or African
□ White
□ Asian

□ Native Hawaiian or other Pacific Islander
□ Indian or Alaska Native
□ Don’t Know

What is your zip

OMB #: 0925-NEW
Expiration Date: xx/xxxx

D6.

What is your highest level of completed education?
□ Less than 8th grade
□ Some high school (no diploma or ged equivalent)
□ Some college (no degree)
□ Bachelors Degree (BA, BS, AB)
□ Professional Degree (JD, PhD, MD, ED)
What is your favorite food?

□ 8th grade
□ High school diploma or ged equivalent
□ Technical or Associate degree
□ Masters Degree (RN,MS,MA)

D7.
D8.

D9.

Are you adopted?
□ Yes □ No
□ I don't know
In general, would you say your health is:
0--------------------------1-------------------------2------------------------3-----------------------4
Poor

D10.

D11.

D12.

Fair

Good

Very Good

Excellent

On a scale from 1 to 7, where 1 is not at all happy and 7 is very happy, how happy do you feel in general?
1-------2-------3-------4-------5-------6-------7
Not at all happy
Very happy
On a scale from 1 to 7, where 1 is not at all stressed and 7 is very stressed, how stressed do you feel in
general?
1-------2-------3-------4-------5-------6-------7
Not at all stressed
Very stressed
Have you ever had a genetic screening?
□ Yes □ No
□ I don't know