Form B1 3Ps_Demographic Intake Form_revised

Healthy Start Demographic Screening Tool | August 2016

OMB #: 0915-0338

Expiration Date: 06/30/2017

Name: _________________________________________________________

Completed by: _______________________ Date of Administration: ___________________

To be completed with each participant at intake.

Please read the following statement to the participant: Thank you for taking time to complete this interview. Any information you provide will be kept confidential to the extent allowed by law. You do not have to answer any question you do not want to, and you can end the interview at any time.

1. What is your date of birth?

____/____/________ (month/day/year)

2. What is your address:

Number and Street: ________________________­­­­­­­­­­­­__________________

Town/City: ___________________ State: ________________________ Zip Code: ___________

Home Phone: ________________ Cell Phone: __________________

Email address:

3. What is the best way to contact you?

• Home phone

• Cell phone

• Text

• Email

4. Emergency Contact info:

Name: ___________________________

Home phone: ______________________

Cell phone: _______________________

Relationship: ______________________

5. What is the highest grade or year of school you have completed?
Select one only.

• Less than high school

• High school graduate or GED completed

• Some college/ vocational school

• College graduate

• More than college

• Don't Know

• Declined to answer

6. Are you of Hispanic, Latino, or Spanish origin?

Select all that apply.

• No, not of Hispanic, Latino, or Spanish origin

• Yes, Mexican, Mexican Am., Chicano

• Yes, Puerto Rican

• Yes, Cuban

• Yes, another Hispanic, Latino, or Spanish origin — Print origin, for example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. __________________________________

7. What is your race?

Select all that apply.

• White

• Black or African American

• American Indian or Alaska Native

• Asian Indian

• Chinese

• Filipino

• Japanese

• Korean

• Vietnamese

• Other Asian

• Native Hawaiian

• Guamanian or Chamorro

• Samoan

• Other Pacific Islander

8. Were you born in the United States, including the Virgin Islands?

Select one only.

• Yes, born in the United States (Go to Question 9)

• No, not born in the United States (Go to Question 8.1)

• Don’t know (Go to Question 9)

• Declined to answer (Go to Question 9)

8.1 What country were you born in?

Country:_______________________________

• Don’t know

• Declined to answer

8.2 When did you come to live in the United States?

Year____________

9. How well do you speak English? Would you say very well, well, not well, or not at all?

Select one only.

• Very well

• Well

• Not well

• Not at all

• Don’t know

• Declined to answer

10. Do you speak a language other than English at home?

Select one only.

• Yes (Go to question 10.1)

• No [Screening Tool is complete]

• Don’t know [Screening Tool is complete]

• Declined to answer [Screening Tool is complete]

10.1. What is this language?

Select one only.

Staff: DO NOT READ OUT LOUD:

• African language (please specify):
  _____________________

• Arabic

• Chinese (please specify):
  _____________________

• Cape Verdean Creole

• English

• French

• German

• Greek

• Haitian Creole

• Hebrew

• Hindi

• Italian

• Japanese

• Korean

• Persian

• Polish

• Portuguese

• Russian

• Spanish

• Tagalog

• Vietnamese

• Urdu

• Other language (please specify):
  ____________________

• Declined to answer

The Healthy Start Demographic Screening Tool is Complete

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