Basic survey questionnaire

BASIC SURVEY QUESTIONNAIRE

Name : [INSERT THE NAME]

Address : [SPECIFY THE ADDRESS]

Date : 00.00.20_

Respondent Information:

What is your age?

◻ Under 12 years old

◻ 12-17 years old

◻ 18-24 years old

◻ 25- 34 years old

◻ 35-44 years old

◻ 45-54 years old

What is your gender?

◻ Male ◻ Female

What is your ethnicity or race?

◻ White

◻ Spanish

◻ Latino

◻ Black or African American

◻ Native American

◻ Asian or Pacific Islander

◻ Others, please specify [ ]

What is your highest degree or level of education?

◻ No schooling completed

◻ High School Graduate

◻ Vocational Training

◻ Associate Degree

◻ Bachelor’s Degree

◻ Master’s Degree

◻ Doctoral Degree

What is your marital status?

◻ Single, never married

◻ Divorced

◻ Married

◻ Widowed

◻ Separated

What is your employment status?

◻ Employed, minimum wage

◻ Employed, above minimum wage

◻ Self-employed

◻ Homemaker

◻ Student

◻ Military

◻ Not able to work (PWD)

What is the total annual income of your household?

◻ $0 to $29,999.99

◻ $30,000.00 to $49,999.99

◻ $50,000.00 to $69,999.99

◻ $70,000.00 to $89,999.99

◻ Confidential

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Basic survey questionnaire (English)

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