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