Social Determinants of Health Survey Question Title * 1. Age 0 100 Clear i We adjusted the number you entered based on the slider’s scale. Question Title * 2. Gender Question Title * 3. The ethnicity you most identify with? White American Black/African American Asian American Multiracial Native American/Alaska Natives Native Hawaiians/Pacific Islanders Hispanic/Latino American Middle Easterner/North African Other Other (please specify) Question Title * 4. The culture you most identify with? Question Title * 5. For each of the following characteristics, please rate on a scale of 1 to 10 how they have given you privilege over others: 1 (has given little to no privilege) 2 3 4 5 6 7 8 9 10 (has given a lot of privilege) Not applicable Skin Color Skin Color 1 (has given little to no privilege) Skin Color 2 Skin Color 3 Skin Color 4 Skin Color 5 Skin Color 6 Skin Color 7 Skin Color 8 Skin Color 9 Skin Color 10 (has given a lot of privilege) Skin Color Not applicable Hair color Hair color 1 (has given little to no privilege) Hair color 2 Hair color 3 Hair color 4 Hair color 5 Hair color 6 Hair color 7 Hair color 8 Hair color 9 Hair color 10 (has given a lot of privilege) Hair color Not applicable Cultural Identity Cultural Identity 1 (has given little to no privilege) Cultural Identity 2 Cultural Identity 3 Cultural Identity 4 Cultural Identity 5 Cultural Identity 6 Cultural Identity 7 Cultural Identity 8 Cultural Identity 9 Cultural Identity 10 (has given a lot of privilege) Cultural Identity Not applicable Sexual Orientation Sexual Orientation 1 (has given little to no privilege) Sexual Orientation 2 Sexual Orientation 3 Sexual Orientation 4 Sexual Orientation 5 Sexual Orientation 6 Sexual Orientation 7 Sexual Orientation 8 Sexual Orientation 9 Sexual Orientation 10 (has given a lot of privilege) Sexual Orientation Not applicable Gender Gender 1 (has given little to no privilege) Gender 2 Gender 3 Gender 4 Gender 5 Gender 6 Gender 7 Gender 8 Gender 9 Gender 10 (has given a lot of privilege) Gender Not applicable Disability Status Disability Status 1 (has given little to no privilege) Disability Status 2 Disability Status 3 Disability Status 4 Disability Status 5 Disability Status 6 Disability Status 7 Disability Status 8 Disability Status 9 Disability Status 10 (has given a lot of privilege) Disability Status Not applicable Mother's Profession Mother's Profession 1 (has given little to no privilege) Mother's Profession 2 Mother's Profession 3 Mother's Profession 4 Mother's Profession 5 Mother's Profession 6 Mother's Profession 7 Mother's Profession 8 Mother's Profession 9 Mother's Profession 10 (has given a lot of privilege) Mother's Profession Not applicable Father's Profession Father's Profession 1 (has given little to no privilege) Father's Profession 2 Father's Profession 3 Father's Profession 4 Father's Profession 5 Father's Profession 6 Father's Profession 7 Father's Profession 8 Father's Profession 9 Father's Profession 10 (has given a lot of privilege) Father's Profession Not applicable Home Location Home Location 1 (has given little to no privilege) Home Location 2 Home Location 3 Home Location 4 Home Location 5 Home Location 6 Home Location 7 Home Location 8 Home Location 9 Home Location 10 (has given a lot of privilege) Home Location Not applicable High School Attended High School Attended 1 (has given little to no privilege) High School Attended 2 High School Attended 3 High School Attended 4 High School Attended 5 High School Attended 6 High School Attended 7 High School Attended 8 High School Attended 9 High School Attended 10 (has given a lot of privilege) High School Attended Not applicable College Attended College Attended 1 (has given little to no privilege) College Attended 2 College Attended 3 College Attended 4 College Attended 5 College Attended 6 College Attended 7 College Attended 8 College Attended 9 College Attended 10 (has given a lot of privilege) College Attended Not applicable Question Title * 6. Were your ancestors forced to come to this country or forced to relocate from where they were living permanently? Yes No Question Title * 7. Were your ancestors restricted from living in certain areas? Yes No Question Title * 8. Would you identify your primary ethnicity to be “American?” Yes No Question Title * 9. Were you ever called names or ridiculed because of your race? Yes No Question Title * 10. Were you ever called names or ridiculed because of your ethnicity? Yes No Question Title * 11. Were you ever called names or ridiculed because of your class background? Yes No Question Title * 12. Were you ever called names or ridiculed because of your cultural identity? Yes No Question Title * 13. Did you grow up with people of color or working class people who were servants, maids, gardeners, or babysitters in your house? Yes No Question Title * 14. Were you ever embarrassed or ashamed of your clothes, your house, or your family when growing up? Yes No Question Title * 15. Are any members of your immediate family doctors, lawyers, or other professionals? Yes No Question Title * 16. Are pimping and prostitution, drugs, or other illegal activities major occupational alternatives in the community where you were raised? Yes No Question Title * 17. Have you ever tried to change your physical appearance, mannerisms, language, or behavior to avoid being judged or ridiculed? Yes No Question Title * 18. Did you study the history and culture of your ethnic ancestors in elementary and/or secondary school? Yes No Question Title * 19. Did you start school speaking a language other than English? Yes No Question Title * 20. Did your family have more than 50 books in the house when you were growing up? Yes No Question Title * 21. Did you ever skip a meal or go away hungry from a meal because there wasn't enough money to buy food in your family? Yes No Question Title * 22. Were one of your parents ever laid off, unemployed, or underemployed not by choice? Yes No Question Title * 23. Have you ever attended a private school or summer camp? Yes No Question Title * 24. Have you ever received less encouragement in academics or sports from your family or from teachers because of your gender? Yes No Question Title * 25. Did you or your family ever have to move because there wasn't enough money to pay rent? Yes No Question Title * 26. Were you told by your parents that you were beautiful, smart, and capable of achieving your dreams? Yes No Question Title * 27. Were you ever discouraged or prevented from pursuing academic or work goals, or tracked into a lower level because of your race, class, or ethnicity? Yes No Question Title * 28. Did your parents encourage you to go to college? Yes No Question Title * 29. Did you grow up in a single parent household? Yes No Question Title * 30. Did you take a vacation outside of your home state prior to your 18th birthday? Yes No Question Title * 31. Did both of your parents complete high school? Yes No Question Title * 32. Do your parents own their house? Yes No Question Title * 33. Do you commonly see people of your race or ethnicity on television or in the movies in roles that you consider to be degrading? Yes No Question Title * 34. Have you ever got a good paying job or a promotion because of a friend or family member? Yes No Question Title * 35. Have you ever been denied a job/position because of your race or ethnicity? Yes No Question Title * 36. Have you ever been mistrusted or accused of stealing, cheating, or lying because of your race, ethnicity, or class? Yes No Question Title * 37. Do you primarily use public transportation to get where you need to go? Yes No Question Title * 38. Do you generally think of the police as people that you can call for help in times of emergencies? Yes No Question Title * 39. Have you ever felt afraid of violence directed toward you because of your race? Yes No Question Title * 40. In general, are you able to avoid communities or places that you consider dangerous? Yes No Question Title * 41. Have you ever felt uncomfortable or angry about a remark or joke made about your race or ethnicity but didn't feel it was safe to confront it? Yes No Question Title * 42. Have you or close friends or family ever been a victim of violence because of your race or ethnicity? Yes No Question Title * 43. Were your parents raised outside of the United States? Yes No Done
