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Parent/Caregiver Survey 2026-2027
Demographics
Please take a few minutes to fill out this short survey about tobacco. Your responses will be kept private. This information will only be used to make improvements to our tobacco education program. Thank you!
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1.
What Indiana County do you live in?
(Required.)
Adams
Allen
Bartholomew
Benton
Blackford
Boone
Brown
Carroll
Cass
Clark
Clay
Clinton
Crawford
Daviess
Dearborn
Decatur
DeKalb
Delaware
Dubois
Elkhart
Fayette
Floyd
Fountain
Franklin
Fulton
Gibson
Grant
Greene
Hamilton
Hancock
Harrison
Hendricks
Henry
Howard
Huntington
Jackson
Jasper
Jay
Jefferson
Jennings
Johnson
Knox
Kosciusko
LaGrange
Lake
La Porte
Lawrence
Madison
Marion
Marshall
Martin
Miami
Monroe
Montgomery
Morgan
Newton
Noble
Ohio
Orange
Owen
Parke
Perry
Pike
Porter
Posey
Pulaski
Putnam
Randolph
Ripley
Rush
St. Joseph
Scott
Shelby
Spencer
Starke
Steuben
Sullivan
Switzerland
Tippecanoe
Tipton
Union
Vanderburgh
Vermillion
Vigo
Wabash
Warren
Warrick
Washington
Wayne
Wells
White
Whitley
I do not live in Indiana
2.
What is your age?
under 18
18-25
26-35
36-45
46-54
55+
3.
What is your race and/or ethnic background? (Check all that apply)
White
Black
Latino
Asian
Native Hawaiian/Pacific Islander
Native American/Native Alaskan
Other (please specify)
4.
What is your sex/gender
Male
Female
Other (please specify)
5.
What is your household's annual income?
less than $15,000
$15,000-$24,999
$25,000-$34,999
$35,000-$49,999
over $50,000
6.
Which of the following relationships do you have with young children? ("Young children" refers to children under the age of 10) Check all that apply.
Parent
Step-Parent
Foster Parent/Guardian
Grandparent
Aunt/Uncle
Sibling
Teacher/Childcare Provider
I do not have any relationships with young children.
Other (please specify)
Current Progress,
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