2013 Kidney Walk Survey

SECTION 1:

Help us get to know you so we can better serve you and your interests in NKF and the fight against chronic kidney disease. This survey will take approximately 10 minutes to complete.

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* 1. What is your gender?

a. Male

b. Female

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* 2. What is your age range?

a. Under 18

b. 18-24

c. 25-34

d. 35-44

e. 45-54

f. 55-64

g. 65+

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* 3. What is your education level?

a. Less than/some high school

b. Graduated high school

c. Some college

d. College graduate

e. Some post graduate work

f. Post graduate degree

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* 4. Which of the following best represents your racial or ethnic heritage? Choose all that apply.

a. White

b. Black, African American

c. American Indian or Alaska Native

d. Asian Indian

e. Chinese

f. Filipino

g. Japanese

h. Korean

i. Vietnamese

j. Other Asian

k. Native Hawaiian

l. Guamanian or Chamorro

m. Samoan

n. Other Pacific Islander

Other (please specify)

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* 5. What is your approximate Annual Household Income?

a. Less than $25,000

b. $25,000-$49,999

c. $50,000-$74,999

d. $75,000-$99,999

e. $100,000-$124,999

f. $125,000-$149,999

g. $150,000-$199,999

h. $200,000-$299,999

i. $300,000-$499,999

j. $500,000 or more

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* 6. What is the total number of people in your household?

a. 1

b. 2

c. 3

d. 4

e. 5 +

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* 7. If you have children in your household, what are their age ranges? (Check all that apply.)

a. No children

b. 5 years and younger

c. 6-8 years

d. 9-12 years

e. 13-17 years

f. 18 years or older

g. Prefer not to answer

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* 8. Are you a registered organ donor?

a. Yes

b. No

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* 9. If not, have you ever considered becoming an organ donor?

a. Yes

b. No

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* 10. Have you donated a kidney?

a. Yes

b. No