LGBT Health Care Experiences

We appreciate your willingness to complete this short survey to help us better understand the healthcare experiences and cancer awareness of the LGBTQ population in the greater Sacramento region. To be eligible to take the survey, you need to be 18 years of age or older, self-identified as LGBTQ, and living in the greater Sacramento region. The survey should take 5-10 minutes to complete. Please answer each question. You may opt out of the survey at any time. Thank you so much.

1. Which category below includes your age?

Which category below includes your age? 18-20

21-29

30-39

40-49

50-59

60 or older

2. What is your current gender identity?

What is your current gender identity? Male

Female

Transgender Male/Transman

Transgender Female/Transwoman

Genderqueer

Decline to Answer

Other (please specify)

3. What sex were you assigned at birth?

What sex were you assigned at birth? Male

Female

Decline to Answer

4. With what ethnicity/race do you identify?

With what ethnicity/race do you identify? Hispanic or Latino

Asian American

Black or African American

Caucasian/white

Native Hawaiian or Other Pacific Islander

American Indian/Alaska Native

Multiracial

Other (please specify)

5. What was the highest grade or year of school you completed?

What was the highest grade or year of school you completed? Never attended

Elementary School (6th grade) or less

Less than high school

High school diploma

Trade or Vocational School

Some college

College degree

Some postgraduate work

Master’s Degree (M.S., M.A., MBA, etc.)

Doctoral Degree (Ph.D., L.L.D., M.D., etc.)

Other (please specify)

6. Would you prefer that your sexual orientation and gender identity be included in your medical record?

Would you prefer that your sexual orientation and gender identity be included in your medical record? Yes

Not sure

7. What is your approximate average household income?

What is your approximate average household income? $0-$24,999

$25,000-$49,999

$50,000-$74,999

$75,000-$99,999

$100,000-$124,999

$125,000-$149,999

$150,000-$174,999

$175,000-$199,999

$200,000 and up

8. In what ZIP code is your home located? (enter 5-digit ZIP code; for example, 00544 or 94305)

In what ZIP code is your home located? (enter 5-digit ZIP code; for example, 00544 or 94305)

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