Study participants baseline interview

SHIPS
Page 1

Baseline Interview: Demographics
Record ID.

__________________________________

Baseline Interview: Demographics
(Please repeat the reminder below if it has not been provided during this interview period.)
Reminder about resources to help you cope with distress.  
"When you enrolled in this study, you were provided with a list of resources to help you cope
with negative feelings and reactions to these interviews.  These resources can also help you
with other problems in your life not related to the study.
If you do not remember receiving this information, we will provide it to you immediately
following this interview."
Interviewer prompt:
"I'm going to start by asking you a few basic questions about yourself."
What is your age in years?

05/01/2024 12:09pm

__________________________________

projectredcap.org

Page 2

What is your primary language?

You indicated that you speak a primary language not
specified in this list. What is that language?
What is your race/ethnicity? You can make multiple
selections.

You indicated that your race or ethnicity is not
specified in this list. What is that race or
ethnicity?

English
Spanish
American Sign Language
Arabic
Armenian
Cambodian
Cantonese
Farsi
French
Hebrew
Hmong
Ilocano
Italian
Japanese
Korean
Lao
Mandarin
Mien
Polish
Portugese
Russian
Samoan
Tagalog
Thai
Turkish
Other
Prefer not to answer
(Please ask subject their primary language without
reading list.)

__________________________________
African/Africa American/Black
America Indian/Alaskan Native
Asian
Hispanic/Latino
Pacific Islander
White/Caucasian
Other
Prefer not to answer
(Please select all that apply.)

__________________________________

What sex were you assigned on your original birth
certificate?

Male
Female
Other
Prefer not to answer

What is the highest level of education you have
attained?

Less than high school
High school or GED
Some college
College graduate
Some graduate or professional school
Prefer not to answer

05/01/2024 12:09pm

projectredcap.org

Page 3

What is your marital/relationship status?

What is your military status?

You indicated that your military status was not
listed. What is your current military status?

05/01/2024 12:09pm

not married
married and living together
married and living apart
not married but living together
divorced
widowed
prefer not to answer
(Please select all that apply.)
Never served in the military
Currently active duty
Currently reserve duty of National Guard
Previously served in the US military and received
honorable or general discharge
Previously served in the US military and received
entry-level separation or other than honorable
discharge
Served in another country's military
Other
Prefer not to answer

__________________________________

projectredcap.org