Demographic Survey - Child Loss Group

At Sharing Kindness we are able to offer our clinician-led peer grief support programs free of charge to participants, in part, due to generous grant funding. Some funders request demographic data from us. Please note that participation in those questions is voluntary and all answers and comments you provide will remain 100% confidential. When we report information to the funders it will be in the aggregate (e.g. 50% of participants own their own home and 50% rent their homes) without any identifying information.

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* 1. Age

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* 2. What languages do you speak? Check all that apply.

English

Portuguese

Spanish

French

Arabic

Mandarin

Hindi

Prefer not to say

Other (please specify)

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* 3. Which of the following best describes you? (Listed in alphabetical order; select all that apply.)

African American or Black

American Indian or Alaska Native

Asian or Asian American

Hispanic, Latinx or Spanish Origin

Middle Eastern or North African

Native Hawaiian or other Pacific Islander

White

Prefer not to answer

Prefer to self-describe:

None of the above

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* 4. Are you married?

Yes

Prefer not to answer

Other (please specify)

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* 5. Which of the following best describes you?

Woman

Man

Non-binary

Agender

Gender fluid

Gender queer

Prefer not to answer

Prefer to self-describe:

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* 6. Are you transgender?

Yes

Prefer not to answer

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* 7. What are your pronouns?

She/Her

He/Him

They/Them

Ze/Zir

Ze/Hir

Prefer not to answer

Prefer to self-describe:

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* 8. What is your employment status?

Full-time

Part-time

Seeking opportunities

Retired

Prefer not to answer

Other (please specify)

None of the above

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* 9. Highest level of education:

High school diploma

Associate's degree

Bachelor's degree

Trade school certificate

Master's degree or higher

Prefer not to answer

Other (please specify)

None of the above

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* 10. What is your annual income level?

<$25,000

$25,000-75,000

$75,000-125,000

>$125,000

Prefer not to answer

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* 11. Do you own or rent your home?

Own

Rent

Prefer not to answer

Other (please specify)

None of the above

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* 12. How would you describe your ability status? (We are interested in this identification regardless of whether you typically request accommodations.) Select all that apply.

A sensory impairment (vision or hearing)

A learning disability or other diagnosis that interferes with your learning or your ability to concentrate (e.g.dyslexia, auditory processing disorder)

A long-term medical illness (e.g. epilepsy, cystic fibrosis)

A long-term mental health condition (e.g. depression, anxiety)

A mobility impairment

A sensory processing or integration disorder

An intellectual disability

A temporary impairment resulting from illness or injury (e.g. broken ankle, surgery)

I do not identify with a disability or impairment

Prefer not to answer

Prefer to self-describe:

None of the above

Demographic Survey - Child Loss Group

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* 1. Age

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* 2. What languages do you speak? Check all that apply.

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* 3. Which of the following best describes you? (Listed in alphabetical order; select all that apply.)

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* 4. Are you married?

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* 5. Which of the following best describes you?

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* 6. Are you transgender?

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* 7. What are your pronouns?

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* 8. What is your employment status?

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* 9. Highest level of education:

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* 10. What is your annual income level?

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* 11. Do you own or rent your home?

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* 12. How would you describe your ability status? (We are interested in this identification regardless of whether you typically request accommodations.) Select all that apply.

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* 13. What else would you like to share about your ability status?