DEMOGRAPHIC QUESTIONS, ADULTS

Sources:

Questions 1 – 5 & 11 Adult BRFSS.

Question 6 Wisconsin Tobacco Survey, CTRI, 2001

Questions 7-9: Adult BRFSS add-on’s

Question 10: Wisconsin Youth Risk Behavior Survey High School Questionnaire, 2001

QUESTION 1:

What is your age? _____

77 Don't Know

99 Refused

QUESTION 2:

What is your sex (or gender)

1 Male

2 Female

77 Don’t Know

99 Refused

QUESTION 3:

How many children live in your household who are...

Please read

1 Less than 5 years old?

2 5 through 12 years old?

3 13 through 17 years old?

99 Refused

QUESTION 4:

What is the highest grade or year of school you completed?

1 Never attended school or only attended kindergarten

2 Grades 1 through 8(Elementary)

3 Grades 9 through 11 (Some high school)

4 Grade 12 or GED (High school graduate)

5 College 1 year to 3 years (Some college or technical school

6 College 4 years (College graduate)

7 Graduate School(Advance Degree)

99 Refused

 

QUESTION 5:

Please stop me when I get to the category that best describes your annual household income from all sources. Is your annual household income... OR

What category best represents your annual household income?

1 Less than $20,000

2 Between $20,000 and $29,999

3 Between $30,000 and $39,999

4 Between $40,000 and $49,999

5 Between $50,000 and $59,999

6 Between $60,000 and $69,999

7 Between $70,000 and $79,999

8 Between $80,000 and $89,999

9 Between $90,000 and $99,999

10 Over $100,000

77 Don't Know/Not sure

99 Refused

QUESTION 6:

Are you currently:

1 "Employed for wages"

2 "Self-employed"

3 "Out of work for more than 1 year"

4 "Out of work for less than 1 year"

5 "A homemaker"

6 "A student"

7 "Retired" or

8 "Unable to work"

9 Refused

(Source: BRFSS, 2001; Question 13.8)

QUESTION 7:

Are you:

1 Married

2 Divorced

3 Widowed

4 Separated

5 Never been married

6 A member of an unmarried couple

9 Refused  

QUESTION 8

Have you ever served on active duty in the United States Armed Forces, either in the regular military or in a National Guard or military reserve unit?

1 Yes

2 No

8 Don't know/Not sure

9 Refused

QUESTION 9:

Which of the following best describes your current military status?

1. Currently on active duty

2. Currently in reserves

3. No longer in military service

7 Don't know/Not sure

9 Refused

QUESTION 10

How do you describe yourself?

1 American Indian or Alaska Native

2 Asian

4. Black or African American

5. Hawaiian or Other Pacific Islander

6. White

9. Refused

QUESTION 11

Are you Hispanic or Latino?

1 Yes

2 No

7 Don't Know, Not Sure

9 Refused

Source: 2001 BRFSS, Question 13.2