PPG Pre Test

Demographics

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1. Gender:

Male

Female

Other (please specify)

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2. Age:

15-17

18-20

21-24

25-44

45-64

65 or older

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3. Race:

American Indian/Alaska Native

Asian

Black/African American

White

Pacific Islander

Multi-racial

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4. Ethnicity:

Haitian

Hispanic

Non-hispanic

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5. Home zip code: (Required.)

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6. Primary Language:

English

Spanish

Haitian Creole

Other (please specify)

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7. Secondary Language:

English

Spanish

Haitian Creole

Other (please specify)

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8. Do you have health insurance (ex. Private Insurance, KidCare, Medicaid)?

Yes

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9. I am a:

Mother

Father

Adult Mentor

Grandparent

Foster Parent

Other (please specify)

PPG Pre Test

Demographics

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* 1. Gender:

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* 2. Age:

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* 3. Race:

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* 4. Ethnicity:

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* 5. Home zip code: (Required.)

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* 6. Primary Language:

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* 7. Secondary Language:

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* 8. Do you have health insurance (ex. Private Insurance, KidCare, Medicaid)?

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* 9. I am a:

1. Gender:

2. Age:

3. Race:

4. Ethnicity:

5. Home zip code: (Required.)

6. Primary Language:

7. Secondary Language:

8. Do you have health insurance (ex. Private Insurance, KidCare, Medicaid)?

9. I am a: