Protective Factors Survey

Client Data

Question Title

* 1. Date

Today's Date

Date

Question Title

* 2. Participant ID

Question Title

* 3. Pre or Post Test

Pre

Post

Question Title

* 4. Sex

Male

Female

Question Title

* 5. Age

Question Title

* 6. Race/Ethnicity: (Please choose the ONE that best describes what you consider yourself to be)

A Native American or Alaskan Native

B Asian

C African American

D African Nationals/Caribbean Islanders

E Hispanic or Latino

F Middle Eastern

G Native Hawaiian/Pacific Islanders

H White (Non Hispanic/European American)

I. Multi-racial

Other (please specify)

Question Title

* 7. Marital Status

A Married

B Partnered

C Single

D Divorced

E Widowed

F Separated

Question Title

* 8. Family Housing

A Own

B Rent

C Shared housing with relatives/friends

D Temporary (shelter, temporary with friends/relatives

E Homeless

Question Title

* 9. Family Income

A $0-$10,000

B $10,001-$20,000

C $20,001-$30,000

D $30,001-$40,000

E $40,001-$50,000

F more than 50,001

Question Title

* 10. Highest Level of Education

A Elementary or junior high school

B Some high school

C High school diploma or GED

D Trade/Vocational Training

E Some college

F 2-year college degree (Associate’s)

G 4-year college degree (Bachelor’s)

H Master’s degree

I PhD or other advanced degree

Question Title

* 11. Which, if any, of the following do you currently receive? (Check all that apply)

A Food Stamps

B Medicaid (State Health Insurance)

C Earned Income Tax Credit

D TANF

E Head Start/Early Head Start Services

F None of the above