U.S. Demographics Template

Question Title

* 1. In what state or U.S. territory do you live?

Question Title

* 2. In what ZIP code is your home located? (enter 5-digit ZIP code; for example, 00544 or 94305)

Question Title

* 3. What is your gender?

Female

Male

Other (specify)

Question Title

* 4. Which category below includes your age?

17 or younger

18-20

21-29

30-39

40-49

50-59

60 or older

Question Title

* 5. Are you Mexican, Mexican-American, Chicano, Puerto Rican, Cuban, Cuban-American, or some other Spanish, Hispanic, or Latino group?

I am not Spanish, Hispanic, or Latino

Mexican

Mexican-American

Chicano

Puerto Rican

Cuban

Cuban-American

Some other Spanish, Hispanic, or Latino group

From multiple Spanish, Hispanic, or Latino groups

Question Title

* 6. Are you White, Black or African-American, American Indian or Alaskan Native, Asian, Native Hawaiian or other Pacific islander, or some other race?

White

Black or African-American

American Indian or Alaskan Native

Asian

Native Hawaiian or other Pacific Islander

From multiple races

Some other race (please specify)