Appendix G – Community Survey Excerpts from Resident Surveys: Questions About Demographics Date of birth:
Which best describes your annual household income?
/ ______ / ______ MM DD YYYY
Under $15,000 ____
______
Gender: Male ____ Female ____
$15,000 to $29,999 ____ $30,000 to $44,999 ____ $45,000 to $59,999 ____ $60,000 to $74,999 ____
Marital status:
$75,000 to $100,000 ____
Single ____ Married ____ Separated ____
Over $100,000 ____
Divorced ____ Widowed ____ Living with significant other ____
Are you currently employed?
Other (specify) ____________________
Full-Time ____ Part-Time ____ Unemployed ____ Retired ____
What is your ethnicity? African
American ____ Asian ____
Latino ____ Caucasian ____ Other (please specify): __________________ What is the highest grade you completed in school?
If you are employed, how many hours per week do you work? Have you been unemployed at any time in the last 3 years?
Less than high school ____
No ____ Yes ____
Some high school ____
If yes, for how long? ________
High school graduate ____ Some college ____
Is your spouse or someone else in your household employed?
College degree ____
Yes, Full-Time ____ Yes, Part-Time ____
Graduate degree ____
Unemployed ____ Retired ____
How many people under 18 years of age in your household? None ____ One ____ Two ____ Three ____ Four ____ Five ____ Six or more ____
No spouse or significant other ____ If they are employed, how many hours per week do they work? Which of the following best describes your household financial situation? Getting ahead/saving money ____ Stable ___ Just able to pay bills ____ Falling behind on bills ____
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