Attachment 4: Demographic Questions
June 21, 2010
Based on the approved data collection instrument downloaded from RegInfo.gov 6/16/2010
Last OMB-approved question: #28
This version includes:
Minor modifications to existing questions, and
Proposed new 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.)
Gender:
Male
Female
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
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: _____________________
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
Variant: Question Stem Changed
Please indicate your race or ethnic background. Are you?
Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Race: SELECT ONE OR MORE.
White/Caucasian
Black or African-American
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Asian
6 Vietnamese
7 Cambodian
8 Filipino
9 Japanese
10 Korean
11 Chinese
Were you born in the United States?
Yes
No
In what state, city, and zip code do you currently live?
Variant:
In what state, city and zip code do you currently live? ENTER FIVE DIGIT ZIP.
What is your current occupational status? Would you say…
Employed
Unemployed
Homemaker
Student
Retired, or
Disabled
Other:_______________
What is your current job title? What term would you use to describe the profession you are in?
_____________________________________________________________________
What is your marital status?
Married
Living as married
Divorced
Widowed
Separated, or
Single, never been married
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
Number of children (under age 18) living in the household:
None
1-2 children
3-4 children
5 or more children
Do you currently rent or own your home?
Own
Rent
Occupied without paying monetary rent
[continue to next page]
Additional Demographic Questions (approved in 2009)
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
Additional Demographic Questions (approved in 2009)
21. Are you the parent or guardian of a [boy/girl], ages [INSERT range] years?
Yes
No
22. What is your age? ___________________ (record age)
23. Are you or have you ever been sexually active?
Yes
No
24. Do you feel comfortable reading materials that require a 7th grade reading level?
Yes
No
25. 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:___________]
26. Describe your work environment:
Hospital
Emergency room
Clinic
Office
Field
Academic
Research
Home or telecommute
[Other:___________]
27. What is your primary specialty?
___ Family Medicine
___ Internal Medicine
___ Obstetrics/Gynecology
___ Oncology
___ Pathology
___ Psychiatry
___ Clinical Genetics
___ Other (please specify): ________________________________________
28. Do you have a subspecialty?
___ Yes (If Yes, please specify, i.e. pediatric oncology, gynecologic oncology, etc.): ________________
___
No
Additional Demographic Questions (proposed June 2010)
29. Have you smoked at least 100 cigarettes in your entire life? SINGLE RESPONSE.
Yes
No
30. Do you now smoke cigarettes every day, some days, or not at all? SINGLE RESPONSE.
Every day
Some days
Not at all
31. During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking? SINGLE RESPONSE.
Yes
No
32. About how long has it been since you completely quit smoking cigarettes? FILL IN NUMBER FOR UNIT THAT APPLIES
_____ Days
_____ Weeks
_____ Months
_____ Years
33. On how many of the past 30 days did you smoke cigarettes?
Enter number: _______
34. On the average, on those (INSERT QUESTION #33 RESPONSE) days, how many cigarettes did you usually smoke each day?
FILL IN NUMBER _______
35. Which of these best describes the area in which you work most of the time?
Mainly work indoors
Mainly work outdoors
Travel to different buildings or sites
In a motor vehicle, or
Somewhere else
Varies
| File Type | application/msword |
| File Title | Attachment 4: Demographic Questions |
| Author | Angela Ryan |
| Last Modified By | arp5 |
| File Modified | 2010-06-21 |
| File Created | 2010-06-16 |