New Survey Part 1

Welcome to Community Action, Inc.! To help you to the be of our ability, we need to know some information about you. Don't worry, this information is anonymous and will be combined with other clients to give us the most information about your community.

Name:

Age:

I identify my gender as:

Woman

Man

__________

Prefer not to answer

Race:

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Two or more races

Are you Hispanic, Latino or of Spanish origin?

Yes

No

How many people (including yourself) live in your household?

1-2

3-5

6-8

9 or more

What is the highest level of education you have completed?

less than 10th grade

some or all of 10th grade

some or all of 11th grade

some of 12th grade

I have a high school diploma or GED

I have certification

I completed some college

I have a college degree

Tell us about your employment:

Full-time or more

Part-time (less than 35 hours a week)

Self-employed

In school, full or part-time

Homemaker

Unemployed

Retired or disabled