Form Demographic Data Demographic Data Demographic Data

Parent-Child Assistance Program

OMB # 0930- XXXX
Expiration Date: xx/xx/xxxx

DEMOGRAPHIC QUESTIONNAIRE

1. Are you Hispanic or Latino?

Yes

No
2. What is your race? (Select all that apply)

Alaska Native

American Indian

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White
3. What is the highest level of education you have finished, whether or not you received a
degree?

Never attended school
th

6 grade or less
th
th

7 - 8 grade
th
th

9 -11 grade
th

12 grade or GED

Equivalent of 1-2 years of college

Equivalent of over 2 years but less than 4 years full-time college
4. What is your marital status?

Married

Unmarried, living with partner

Widowed

Divorced or separated

Never married
Alcohol Assessment
5. During the past 30 days, on how many days did you drink one or more of an alcoholic
beverage?
________days
6. How many drinks did you have on a typical day when you were drinking alcohol in the past
30 days?
0

1

2

3

4

5

6

7

8

9

10
or more

7. How often did you have 4 or more drinks in one day in the past 30 days?
0

1

2

3

4

5

6

7

8

9

10
or more

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. The OMB control number for this project is 0930-xxxx. Public reporting burden for this collection of information is estimated to average 5
minutes per client per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville,
Maryland,20857.