Gloucester County Public Health Survey

1. My age is:

My age is: Under 24

25 to 39

40 to 59

60 and above

2. I am:

I am: Male

Female

3. My height is:

My height is: Feet
Inches

4. My weight is:

My weight is:

5. In my household there is:

In my household there is:

6. In my household there is:

In my household there is:

7. I live in (pay taxes):

I live in (pay taxes):

8. I live with: (Check all that apply)

I live with: (Check all that apply) Spouse/Partner

Children

Other relatives

Unrelated individuals

Alone

I do not want to answer

9. My household income is:

My household income is: Under $15,000

Between $15,000 and $24,999

Between $25,000 and $39,999

Between $40,000 and $69,999

$70,000 and above

I do not want to answer

10. I consider myself: (Please select one)

I consider myself: (Please select one) Caucasian

African-American

Hispanic/Latino

Asian or Pacific Islander

american Indian/Alaska Native

Other/None of the Above

I do not want to answer

11. I am currently:

I am currently: Employed

Temporarily laid off

Retired

Not employed

Unable to work

Full time student

Other

I do not want to answer

12. I pay for health care with:

I pay for health care with: Health insurance (private, HMO)

Medicare/Medicaid

NJ Family Care

Veteran's Administration

I have no insurance

Cash

Other

I do not want to answer

13. In the last 12 months, I have received:

In the last 12 months, I have received: Unemployment compensation

Heating/Utility Assistance

TANF

WIC

PAAD

Social Security

Food Stamps

None of the Above

I do not want to answer

Gloucester County Public Health Survey

1. Demographics

1. My age is:

2. I am:

3. My height is:

4. My weight is:

5. In my household there is:

6. In my household there is:

7. I live in (pay taxes):

8. I live with: (Check all that apply)

9. My household income is:

10. I consider myself: (Please select one)

11. I am currently:

12. I pay for health care with:

13. In the last 12 months, I have received: