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2016
September
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New Survey Part 1
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Welcome to Community Action, Inc.! To help you to the be of our ability, we need to know some information about you. Don't worry, this information is anonymous and will be combined with other clients to give us the most information about your community.
Name:
Age:
16-18
19-25
26-40
41-60
Over 60 years
I identify my gender as:
Woman
Man
__________
Prefer not to answer
Race:
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Two or more races
Are you Hispanic, Latino or of Spanish origin?
Yes
No
How many people (including yourself) live in your household?
1-2
3-5
6-8
9 or more
What is the highest level of education you have completed?
less than 10th grade
some or all of 10th grade
some or all of 11th grade
some of 12th grade
I have a high school diploma or GED
I have certification
I completed some college
I have a college degree
Tell us about your employment:
Full-time or more
Part-time (less than 35 hours a week)
Self-employed
In school, full or part-time
Homemaker
Unemployed
Retired or disabled
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