(en) STIGMATIZATION OF LIVER DISEASES, DOES IT EXIST? (en)

DEMOGRAPHIC DATA

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* 1. Living Country:

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* 2. Today’s date:

Date / Time

Date

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* 3. Postal Code:

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* 4. Birth date:

Date / Time

Date

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* 5. Gender:

Male

Female

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* 6. What would best describe you?

White

Hispanic or Latino

Black or African American

Native American or American Indian

Asian / Pacific Islander

Other

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* 7. MARITAL STATUS: What is your marital status?

Single, never married

Married or domestic partnership

Divorced / Separated

Widowed

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* 8. EDUCATION: What is the highest degree or level of school you have completed? If currently enrolled, highest degree received.

Less than high school diploma

High school diploma or equivalent degree

Bachelor’s degree

Master’s degree

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* 9. Employment Status: What is your current employment status?

Full-time employment

Part-time employment

Unemployed

Self-employed

Home-maker

Student

Retired

Out of work and looking for work

Out of work but not currently looking for work

Unable to work

Other

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* 10. Which income group does your household fall under? (OPTIONAL)

Less than $20,000

$21,000 – $30,000

$31,000 to $40,000

$41,000 to $50,000

$51,000 to $60,000

Above $60,000