Porter County Adult Survey Respondent Information Question Title * 1. What is your gender? Female Male Question Title * 2. What is your age? 17 or younger 18-20 21-29 30-39 40-49 50-59 60 or older Question Title * 3. Which race/ethnicity best describes your child? (Please choose only one.) American Indian or Alaskan Native Asian / Pacific Islander Black or African American Hispanic White / Caucasian Multiple ethnicity / Other (please specify) Question Title * 4. Which of the following best describes your current relationship status? Married Widowed Divorced Separated In a domestic partnership or civil union Single, but cohabiting with a significant other Single, never married Question Title * 5. Which of the following categories best describes your employment status? Employed, working full-time Employed, working part-time Not employed, looking for work Not employed, NOT looking for work Retired Disabled, not able to work Part-time Student Full-time Student Question Title * 6. What is the highest level of school that you have completed? Primary school Some high school, but no diploma High school diploma (or GED) Some college, but no degree 2-year college degree 4-year college degree Graduate-level degree None of the above Question Title * 7. How many people currently live in your household? Question Title * 8. Do you have any children under 18? Yes No Question Title * 9. In what ZIP code is your home located? (enter 5-digit ZIP code; for example, 00544 or 94305) Question Title * 10. Have you heard of the Porter County Substance Abuse Council? Yes No Not sure Next
