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What is your age bracket?
 
under 14
 
15-19
 
20-25
 
26-32
 
33-39
 
40-45
 
46-52
 
53-59
 
60-65
 
66-72
 
73+
 
 
 
What is your gender?
 
Female
 
Male
 
Transgender Female
 
Transgender Male
 
 
 
Ethnicity (check all that apply)
 
African American
 
Asian/Pacific Islander
 
Caucasian/White
 
Hispanic
 
Indigenous or Aboriginal Person
 
Latino
 
Multiracial
 
Other
 
Rather not say

 
 
 
What is your current marital status?`
 
Single
 
Living with another
 
Married
 
Separated
 
Divorced
 
Widowed
 
Rather not say
 
 
 
What is the status of children in the home?
 
I have children
 
I have stepchildren
 
Integrated, my children and step children live together
 
No children, but I want children someday
 
No children, I never want children
 
 
 
Is your home a(an):
 
single family house
 
two family house
 
Apartment
 
Townhouse
 
Condo
 
Mobile home
 
Other
 
 
 
Indicate total household income:
 
under $24,000
 
$24,000 - $29,999
 
$30,000 - $49,999
 
$50,000 - $69,999
 
$70,000 - $84,999
 
$85,000 - $99,999
 
$100,000 - $119,999
 
$120,000 - $149,999
 
$150,000 +
 
Rather Not Say
 
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