Teton County CHNA Community Survey

Personal Background Information

For each question within this section, please select the answer that most applies to your current situation. All responses will be kept confidential.

Question Title

* 1. I am...

Male

Female

Choose to not answer

Question Title

* 2. What was your age on your last birthday?

Under 18

18-24

25-34

35-44

45-54

55-64

65 - 74

75+

Question Title

* 3. My racial/ethnic identification is:

White/Caucasian

Black/African American

Native American

Asian

Hispanic

Multi-Racial

Other (please specify)

Question Title

* 4. What is your highest level of education?

Some high school

High school graduate

Technical school graduate

Some college

College graduate

Graduate school or higher

Question Title

* 5. What is your current employment status?

Employed: Full-Time

Employed: Part-Time

Full-Time Student

Part-Time Student

Homemaker

Retired

Unemployed: Under A Year

Unemployed: More Than One Year

Unemployed: Due To Illness

Question Title

* 6. Which best describes your field?

Management, business, and financial operations

Professional and related occupations

Service occupations

Sales and related occupations

Office and administrative support occupations

Farming, fishing, and forestry occupations

Construction and extraction occupations

Installation, maintenance, and repair occupations

Production occupations

Transportation and material moving operations

Education

Armed Forces

Other (please specify)

Question Title

* 7. What is your total yearly 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

Question Title

* 8. What is the source of your health insurance coverage?

Insurance provided by employer

Insurance I purchased individually

Medicare

Medicaid

Government (VA, Tricare, etc.)

Health Savings Account

Uninsured

Other (please specify)