Santa Barbara Neighborhood Clinics:
Community Outreach and Education

Demographic Information

If you prefer not to answer certain questions, feel to skip them as needed. Your answers will remain strictly confidential. Please provide answers to the best of your knowledge.

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Question Title

* 1. What is your age group?

Under 18

18-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65 and above

Question Title

* 2. Which of the following best describes you?

Asian or Pacific Islander

Black or African American

Hispanic or Latino

Native American or Alaskan Native

White or Caucasian

Multiracial or Biracial

A race/ethnicity not listed here

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* 3. Gender: How do you identify?

Man

Non-binary

Woman

Prefer to self-describe, below

Self-describe:

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* 4. What is the highest level of education you have completed?

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* 5. Which of the following categories best describes your employment status?

Unemployed

Student

Part-time

Full-time

Retired

Disabled, not able to work

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* 6. What is your current annual household income?

Under $15,000

Between $15,000 and $29,999

Between $30,000 and $49,999

Between $50,000 and $74,999

Between $75,000 and $99,999

Between $100,000 and $150,000

Over $150,000

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* 7. What is your residential status?

Renter

Homeowner

Unhoused

Other (please specify)

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* 8. What is the size of your household (yourself included)?

5 or more

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* 9. What is the 5-digit zip code of your residential address?

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* 10. What is your relationship status?

Single

Married

Domestic partnership

Separated

Divorced

Widowed

Other (please specify)

Santa Barbara Neighborhood Clinics: Community Outreach and Education

Demographic Information

Question Title

* 1. What is your age group?

Question Title

* 2. Which of the following best describes you?

Question Title

* 3. Gender: How do you identify?

Question Title

* 4. What is the highest level of education you have completed?

Question Title

* 5. Which of the following categories best describes your employment status?

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* 6. What is your current annual household income?

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* 7. What is your residential status?

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* 8. What is the size of your household (yourself included)?

Question Title

* 9. What is the 5-digit zip code of your residential address?

Question Title

* 10. What is your relationship status?

Santa Barbara Neighborhood Clinics:
Community Outreach and Education