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Surveys
2016
March
J
Jenny Garcia
Jenny Garcia
0%
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: ......................................................
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