VADIC Data Collection Form and Feedback Survey - FY 2018

VADIC Clearinghouse Services: Data Colletion

Please tell us more about yourself. This information will help us fulfill our federal grant requirements and allow us to continue to offer the services of our clearinghouse free to all who use it. Let us know who we are serving, or not serving, in our community. We consider this information private and it will only be reported as part of an aggregate data report. Thank you for your participation.

Question Title

* 1. Are you:

Male

Female

I choose not to respond.

Question Title

* 2. What is your age?

0-4

5-11

12-14

15-17

21-24

25-44

45-64

65+

I choose not to respond.

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* 3. What race best describes you? (You may mark more than one.)

African American / Black

American Indian or Alaska Native

Asian

Native Hawaiian / Pacific Islander

White / Caucasian

I choose not to respond.

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* 4. Are you Hispanic / Latino?

Yes

I choose not to respond.