Background/Demographic Questionnaire Example

Background Questionnaire

Please answer all of the following questions as they describe you.

1. Gender (circle one):



Other: _________

8. Please report an estimate of your household’s combined annual income in thousands of dollars:


2. Age ______ 9. Please circle one of the following to indicate your primary ethnic identity:

A. African American

B. Asian American

C. White, non-Hispanic

D. White, Hispanic

E. Middle Eastern

F. Other: __________________

3. Religion (circle ONE):

A. Christian/Catholic

B. Christian/Non-Catholic

C. Jewish

D. Muslim

E. Other _____________

4. What kind of area were you raised in?

A. rural

B. small town

C. suburban

D. urban

E. Other ________

5. Political orientation:

A. very conservative

B. conservative

C. moderate

D. liberal

E. very liberal



6. Sexual orientation:

A. primarily heterosexual

B. primarily bisexual

C. primarily homosexual

D. Other _________________

7. Marital status of parents:

A. Married

B. Separated

C. Divorced

D. Never married

E. Other ________


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