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Community Member Needs Survey
4.
Demographic Information
1.
How many people live in your household?
2.
What is your sex?
Male
Female
3.
What is the primary language spoken in your household?
English
Chinese
French
Italian
Korean
Russian
Spanish
Vietnamese
Other (please specify)
4.
What is your race?
Black/African American
Asian
White
Native Hawaiian
American Indian or Alaska Native
Other (please specify)
5.
What is your age?
6.
What are the ages of the other people living in your home?
Number of People
How many are Ages 0-3?
-- Select an option --
1
2
3
4
5
6
7
8
9
10+
How many are Age 4?
-- Select an option --
1
2
3
4
5
6
7
8
9
10+
How many are Age 5?
-- Select an option --
1
2
3
4
5
6
7
8
9
10+
How many are Ages 6-11?
-- Select an option --
1
2
3
4
5
6
7
8
9
10+
How many are Ages 12-17?
-- Select an option --
1
2
3
4
5
6
7
8
9
10+
How many are Ages 18-24?
-- Select an option --
1
2
3
4
5
6
7
8
9
10+
How many are Ages 25-55?
-- Select an option --
1
2
3
4
5
6
7
8
9
10+
How many are Ages 56-64?
-- Select an option --
1
2
3
4
5
6
7
8
9
10+
How many are Ages 65-74?
-- Select an option --
1
2
3
4
5
6
7
8
9
10+
How many are Age 75 or older?
-- Select an option --
1
2
3
4
5
6
7
8
9
10+