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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