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2016
September
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Name
Age:
16-18
18-25
26-40
41-60
60+
I identify as:
man
woman
_____________
prefer not to answer
How many people (including yourself) are in your household?
1-3
3-5
6-8
8+
Race
Native American
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
Two or more races
Other
Are you Spanish/Hispanic/Latino?
Yes
No
Highest level of education completed:
Less than 10th grade
Some or all of 10th grade
Some or all of 11th grade
Some of 12th grade
High school diploma
GED
Trade school
Associates (2 yr degree)
Bachelors (4 yr degree)
Other
Tell us about your employment:
full-time or more
part-time (less than 35 hours per week)
self-employed
in school, full or part-time
homemaker
unemployed
retired or disabled
Helpful to me
Not helpful
Comments/Suggestions:
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