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Combine Demographic Form (DEM Ver. B) : Date Entered: - Staff Initials
Combine Demographic Form (DEM Ver. B) : Date Entered: - Staff Initials
Combine Demographic Form (DEM Ver. B) : Date Entered: - Staff Initials
0 1 /
mo. da.
/
yr.
Instructions: Note participants must be > 18 years of age to be eligible for randomization. 1. Sex: (1) Male (2) Female
2.
Date of Birth
month
/
day
/19
year
3.
(7) Partner
4.
Tribe:______________________________
(Specify)
(2) Asian or Asian American (3) Pacific Islander (4) Black or African American (5) Hispanic, Cuban (6) Hispanic, Mexican (7) Hispanic, New Mexican (or Spanish-American) (8) Hispanic, Puerto-Rican (9) Hispanic, Other Latin American (10) White, not of Hispanic origin
DEM_6 (04/02/02)
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Center
Participant # Date
Participant Initials
Week Staff ID
Sequence
0 1 /
mo. da.
/
yr.
5.
Give participant page 3 and document origin/descent next to 5a through 5g. Here is a list of origins and descents. Please indicate origin or descent for yourself, mother, father, and grandparents
6. What is your current employment status? (check one) (1) Homemaker (if yes, also give the usual occupation of spouse)_________________________
(Specify)
(3) Unemployed (4) Retired (5) Currently working full-time (usual occupation)_________________________
(Specify)
(7) Other_________________________
(Specify)
7. How many years of education have you completed? (GED = 12)_______ 8. What is the total yearly income, earned by all family members living in your household, before taxes (check one)? (1) Less than $15,000 (3) $30,000 - $59,999 (5) Over $90,000 (2) $15,000 - $29,999 (4) $60,000 - $89,999
DEM_6 (04/02/02)
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Origin/Descent Code
01 Afghanistani 02 African (i.e. Egyptian, Nigerian, Algerian) 03 African-American (Black, Negro, or AfroAmerican) 04 Aleutian Islander 05 American Indian/Native American 06 American, NOS 07 Australian 08 Australian Aboriginal 09 Austrian 10 Belgian 11 Brazilian 12 Canadian 13 Caribbean or West Indian (Spanish-speaking) 14 Caribbean or West Indian (Non-Spanishspeaking) 15 Central American (i.e., Nicaraguan, Guatemalan) 16 Chicano 17 Chinese 18 Cuban 19 Czechoslovakian, Bohemian 20 Danish 21 Dutch 22 English 23 Filipino 24 Finnish 25 French 26 German 27 Greek 28 Guamanian 29 Hungarian 30 Indian, Afghan 31 Indonesian 32 Iranian 33 Iraqi 34 Irish 35 Israeli 36 Italian 37 Japanese 38 Jordanian 39 Korean 40 Lebanese 41 Malaysian 42 Mexican 43 Mexican-American 44 New Zealander
DEM_6 (04/02/02)
45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67
Norwegian Pakistani Polish Portuguese Puerto Rican Russian Scottish Samoan Spanish Swedish Swiss Taiwanese Torres Strait Islander Turkish Vietnamese Welsh Yugoslavian Other Asian (i.e., Thai, Laotian, Cambodian, Burmese) Other Eastern European (i.e., Romanian, Bulgarian, Albanian) Other Middle Eastern (i.e., Arabian, Saudi, Kuwaiti, Qatari, Syrian, Omani) Other Pacific Islander (i.e., Okinawan, Tahitian) Other South American (i.e., Chilean, Columbian) Other
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