SURVEY OF ADULT AND AGING POPULATIONS Core Questionnaire (SAMPLE) Section I: Demographics Yes No Personal Data (Please Print): Decline to State (11) Employment: (1) The town/city that I live in or zip code: Full Time Unemployed ____________ Part Time Retired Decline to State (2) I have lived in this community for: ___years ___months Racial and Ethnic Background: (3) Birth Date or Age: (12) Ethnicity: _________________ Not Hispanic/Latino Hispanic/Latino (if yes, check one) (4) Gender: Mexican, Mexican American Male Female Transgender Puerto Rican Decline to State Cuban Other _____________ (5) Marital Status: Decline to State Single (never married) Married Domestic Partner Separated Divorced Widowed (13) Race: Decline to State White Black American Indian/Alaska Native (6) Sexual Orientation: Other Race Heterosexual Bisexual Multiple Race Gay Lesbian Asian: Decline to State Asian Indian Cambodian Chinese Filipino Japanese Korean (7) Education (highest grade level completed): Laotian Vietnamese Other Asian 0-8th Grade Some College Hawaiian/Other Pacific Islander: 9-12th Grade College Degree Guamanian Hawaiian Samoan Post Graduate Degree Other Pacific Islander Decline to State Decline to State (8) Impairments: (14) Primary Language: Physical (e.g. hearing, vision, mobility) _____________________ Cognitive (e.g. Dementia, Alzheimer’s) Decline to State (15) Ability to Speak English: Very Well Less Than “Very Well” Financial Information: Not at All Decline to State (9) Approximate Household Income (include all members): $___________ per month year Decline to State Household Arrangement: (10) SSI/SSP: (16) Living Arrangement:
SURVEY OF ADULT AND AGING POPULATIONS Core Questionnaire (SAMPLE) Section I: Demographics Personal Data (Please Print): (1) The town/city that I live in or zip code: ____________ (2) I have lived in this community for: ___years ___months (3) Birth Date or Age: _________________ (4) Gender: Male Female Transgender Decline to State (5) Marital Status: Single (never married) Married Domestic Partner Separated Divorced Widowed Decline to State (6) Sexual Orientation: Heterosexual Bisexual Gay Lesbian Decline to State (7) Education (highest grade level completed): 0-8th Grade Some College 9-12th Grade College Degree Post Graduate Degree Decline to State (8) Impairments: Physical (e.g. hearing, vision, mobility) Cognitive (e.g. Dementia, Alzheimer’s) Decline to State Financial Information: (9) Approximate Household Income (include all members): $___________ per month year Decline to State (10) SSI/SSP: Yes No Decline to State (11) Employment: Full Time Unemployed Part Time Retired Decline to State Racial and Ethnic Background: (12) Ethnicity: Not Hispanic/Latino Hispanic/Latino (if yes, check one) Mexican, Mexican American Puerto Rican Cuban Other _____________ Decline to State (13) Race: White Black American Indian/Alaska Native Other Race Multiple Race Asian: Asian Indian Cambodian Chinese Filipino Japanese Korean Laotian Vietnamese Other Asian Hawaiian/Other Pacific Islander: Guamanian Hawaiian Samoan Other Pacific Islander Decline to State (14) Primary Language: _____________________ (15) Ability to Speak English: Very Well Less Than “Very Well” Not at All Decline to State Household Arrangement: (16) Living Arrangement:
Survey%20of%20Aging%20and%20Adult%20Populations%20(Core_Questionnaire)%20(rev%2003-2016).docx