GynIII Refuser

Current Date

Month	Day	Year

Birth Year:

Home zip code:

What is your ethnicity?

Latina/Latino/Hispanic ancestry

Not Hispanic

What is your racial group? (You may choose more than one)

Caucasian / White

African-American / Black

Asian

American Indian / Alaskan Native

Native Hawaiian / Other Pacific Islander

Other

Have you ever been or are you currently married?

Single, never married

Currently married

Not married, but in a relationship with significant other

Separated or divorced

No longer married, widowed

Are you currently living with a romantic partner?

Yes

No

How long (in years) have you been married? If you are living with a romantic partner, how long (in years) have you been living together?

How many individuals are living in your household?