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2022 LGBT Community Health Survey
GENERAL INFORMATION
In order to protect your identity we have created a Unique Identifier System instead of asking your name.
1.
What is your date of birth (Example 17th)
(Required.)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
2.
What are the LAST two digits of your Social Security Number? (If none, answer 99)
(Required.)
3.
What is your Middle Initial? (If none, answer "Z")
(Required.)
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
U
V
W
X
Y
Z
4.
What are the last two digits of the year you were born? ( ex: You would enter 80 if you were born in 1980)
(Required.)
5.
What is your zip code?
(Required.)
6.
Do you consider yourself:
(Required.)
Lesbian
Gay
Bisexual
Heterosexual
Other (please specify)
7.
Do you consider yourself:
(Required.)
Female
Male
Trans Male
Trans Female
Non-Binary
8.
What is your ethnicity?
(Required.)
Asian
Black or African American
Hispanic or Latino
Middle Eastern or North African
Multiracial or Multiethnic
Native American or Alaska Native
Native Hawaiian or other Pacific Islander
White
Other, please describe below
