ICA Community Survey

DEMOGRAPHICS

Question Title

Sex assigned at birth:

Male

Female

Prefer not to say

Other (please specify)

Question Title

What is your age?

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Are you Hispanic, Latino/a, or Spanish origin?

Yes

Prefer not to say

Question Title

Which one or more of the following would you say is your race? (Please select all that apply.)

White

Black or African American

American Indian or Alaska Native

Asian

Pacific Islander

Prefer not to say

Other (please specify)

Question Title

Geographic Location:

Urban (High population density with extensive infrastructure and amenities, typically found in cities.)

Suburban (Residential areas on the outskirts of cities, offering a mix of homes, schools, and parks.)

Rural (Low population density with large open spaces, often dominated by natural landscapes and farmlands.)

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Education Level:

Have not obtained a GED or completed high school

GED

High school diploma

Some college

Associate’s degree

Bachelor’s degree

Master’s degree

Doctorate's degree

Question Title

What is your current employment status? (Please select the option that BEST describes you.)

Employed full-time

Employed part-time

Self-employed

In the military

Out of work for 1 year or more

Out of work for less than 1 year

A homemaker

A student

Retired

Unable to work

Prefer not to say

Question Title

What best describes your connection with IC/BPS?

I am an IC/BPS patient

I am a friend or family member of an IC/BPS patient

I am a care partner of an adult IC/BPS patient

I am a parent or caregiver of a child with IC/BPS

I am a healthcare provider/practitioner

Other (please specify)

ICA Community Survey

DEMOGRAPHICS

Question Title

* Sex assigned at birth:

Question Title

* What is your age?

Question Title

* Are you Hispanic, Latino/a, or Spanish origin?

Question Title

* Which one or more of the following would you say is your race? (Please select all that apply.)

Question Title

* Geographic Location:

Question Title

* Education Level:

Question Title

* What is your current employment status? (Please select the option that BEST describes you.)

Question Title

* What best describes your connection with IC/BPS?

Sex assigned at birth:

What is your age?

Are you Hispanic, Latino/a, or Spanish origin?

Which one or more of the following would you say is your race? (Please select all that apply.)

Geographic Location:

Education Level:

What is your current employment status? (Please select the option that BEST describes you.)

What best describes your connection with IC/BPS?