Community Programs Survey

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* 1. What is your age?

18 to 24

25 to 34

35 to 44

45 to 54

55 to 64

65 to 74

75 or older

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* 2. What is your gender?

Female

Male

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* 3. Which race/ethnicity best describes you? (Please choose only one.)

American Indian or Alaskan Native

Filipino

Chinese

Vietnamese

Korean

Asian Indian

Black or African American

Hispanic / Latino

White / Caucasian

Multiple ethnicity / Other (please specify)

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* 4. How many people (including yourself) currently live in your household?

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* 5. In what ZIP code is your home located? (enter 5-digit ZIP code; for example, 00544 or 94305)

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

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* 7. What language do you mainly speak at home?

English

Spanish

Tagalog

Some other language