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  2. 2016
  3. March
  4. J
  5. Jenny Garcia
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Exit Survey
 
 
State your gender
 
Male
 
Female
 
 
 
What is your age?
 
Less than 20 years
 
Between 21 and 30 years
 
Between 31 and 40 years
 
More than 40 years
 
 
 
State your race
 
Afro-Trinidadian
 
Indo-Trinidadian
 
Chinese
 
Mixed
 
Other: .........................................
 
 
 
State your religion
 
Christianity
 
Islam
 
Hinduism
 
Other: ............................................
 
 
 
State your marital status
 
Single
 
Married
 
Separated
 
Divorced
 
Widowed
 
Common Law
 
 
 
How many children are dependent on your for time, money, support?
 
Between 1 - 2
 
Between 3 - 4
 
5 or more
 
 
 
Do any of your children have a disability?
 
Yes
 
No
 
 
 
If the answer is Yes, state diagnosis:
   
 
 
 
Do you reside with your child with the disability?
 
Yes
 
No
 
 
 
How often do you visit or provide care for your child with a disability?
 
Daily
 
Weekly
 
Monthly
 
Other: ......................................................