REVISED Health Message Testing System - Attachment 4 - Demographic Questions2.

Attachment 4: Demographic Questions

Attachment 4: Demographic Questions

Form Approved

OMB No. 0920-0572

Expiration Date: 06-30-2011

Demographic Questions

(Questions can be used in intercept interviews, telephone interviews, online research, and focus group screeners.)

1. Gender:

• Male

• Female

2. In which of the following categories does your age fall:

• under 18 years of age

• 18-24 years of age

• 25-34 years of age

• 35-44 years of age

• 45-54 years of age

• 55-64 years of age

• 65-74 years of age

• 75 years of age or older

3. What is the highest level of education you have completed?

• Grade school

• Less than high school graduate/some high school

• High school graduate or completed GED

• Some college or technical school

• Received four-year college degree

• Some post graduate studies

• Received advanced degree

• Other: _____________________

4. Please tell me your race or ethnic background. Are you?

Ethnicity:

• Hispanic or Latino

• Not Hispanic or Latino

Race:

• White/Caucasian

• Black or African-American

• American Indian or Alaska Native

• Native Hawaiian or Other Pacific Islander

• Asian

  • Vietnamese

  • Cambodian

  • Filipino

  • Japanese

  • Korean

  • Chinese

5. Were you born in the United States?

• Yes

• No

6. In what state, city, and zip code do you currently live?

7. What is your current occupational status? Would you say…

• Employed

• Unemployed

• Homemaker

• Student

• Retired, or

• Disabled

• Other:_______________

8. What is your current job title? What term would you use to describe the profession you are in?

_____________________________________________________________________­­­­­­­­­­­­­­­­­­

9. What is your marital status?

• Married

• Living as married

• Divorced

• Widowed

• Separated, or

• Single, never been married

10. Which of the following categories best describe your total, annual household income?

• Under $20,000/year

• $20,001 - $40,000/year

• $30,001 - $60,000/year

• $60,001 - $80,000/year

• $80,001 - $100,000/year

• Over $100,000/year

11. Number of children (under age 18) living in the household:

• None

• 1-2 children

• 3-4 children

• 5 or more children

12. Do you currently rent or own your home?

• Own

• Rent

• Occupied without paying monetary rent

13. What is your current relationship status? Are you…?

• Single

• Married to a man

• Married to a woman

• In a relationship with a man

• In a relationship with a woman

• Divorced or Widowed

• Refused

14. Have you ever had an HIV test?

• Yes

• No

15. What was the result of your last HIV test?

• Positive

• Negative

• Don’t know

16. And when was the last time you had an HIV test? [RECORD DATE]

__________________________

17. Now I am going to ask you to describe your sexual identity. Would you describe yourself as:

• Homosexual or “gay” or same gender loving

• Bisexual or two spirited

• Other, specify____________________________________

• Heterosexual or “straight”

• Don’t know

• Decline to answer

18. Within the past 6 months, who have you primarily had sex with?

• A male

• A female

• Haven’t had sex in the last 6 months

• Refused

19. Within the past 6 months, have you had unprotected sex? By “unprotected sex” we mean having sex without a condom.

• Yes

• No

• Refused

20. Within the past 6 months, have you had sex with more than 1 partner?

• Yes

• No

Requested Additional Questions

1. Are you the parent or guardian of a [boy/girl], ages [INSERT range] years?

• Yes

• No

2. What is your age? ___________________ (record age)

3. Are you or have you ever been sexually active?

• Yes

• No

4. Do you feel comfortable reading materials that require a 7th grade reading level?

• Yes

• No

5. What is your job title or role?

• [Public Health Professional: e.g. epidemiologist, health communicator, health educator, etc]

• [Healthcare Provider: e.g. doctor (MD, DO), nurse, nurse practitioner, physician’s assistant]

• [General Consumer: neither a Public Health Professional nor a Healthcare Provider]

• [Other:___________]

6. Describe your work environment:

• Hospital

• Emergency room

• Clinic

• Office

• Field

• Academic

• Research

• Home or telecommute

• [Other:___________]

7. What is your primary specialty?

___ Family Medicine

___ Internal Medicine

___ Obstetrics/Gynecology

___ Oncology

___ Pathology

___ Psychiatry

___ Clinical Genetics

___ Other (please specify): ________________________________________

 8. Do you have a subspecialty?

___ Yes (If Yes, please specify, i.e. pediatric oncology, gynecologic oncology, etc.): ________________

___ No