Date Entered:___________

Staff Initials:___________
COMBINE
Demographic Form (DEM ver. B)
Center Participant # Participant Initials Week Sequence
0 1
Date Staff ID
/ /
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 / /19

month day year

3. Marital Status
(1) Single (3) Separated (5) Widow(er) (7) Partner
(2) Married (4) Divorced (6) Cohabiting

4. Race/Ethnicity

(1) American Indian or Alaskan Native 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
(11) Bi- or multi-racial
(12) Other ethnic group:______________________________
(Specify)

DEM_6 (04/02/02) Page 1 of 3

 Date Entered:___________
Staff Initials:___________

Center Participant # Participant Initials Week Sequence

0 1
Date Staff ID
/ /
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

5a. Participant 5e. Maternal Grandfather

5b. Mother 5f. Paternal Grandmother

5c. Father 5g. Paternal Grandfather

5d. Maternal Grandmother

6. What is your current employment status? (check one)

(1) Homemaker (if yes, also give the usual occupation of spouse)_________________________
(Specify)
(2) Disabled (usual occupation)_________________________
(Specify)
(3) Unemployed
(4) Retired
(5) Currently working full-time (usual occupation)_________________________
(Specify)
(6) Currently working part-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) Page 2 of 3

 Date Entered:___________
Staff Initials:___________
Origin/Descent Code

01 Afghanistani 45 Norwegian
02 African (i.e. Egyptian, Nigerian, Algerian) 46 Pakistani
03 African-American (Black, Negro, or Afro- 47 Polish
American) 48 Portuguese
04 Aleutian Islander 49 Puerto Rican
05 American Indian/Native American 50 Russian
06 American, NOS 51 Scottish
07 Australian 52 Samoan
08 Australian Aboriginal 53 Spanish
09 Austrian 54 Swedish
10 Belgian 55 Swiss
11 Brazilian 56 Taiwanese
12 Canadian 57 Torres Strait Islander
13 Caribbean or West Indian (Spanish-speaking) 58 Turkish
14 Caribbean or West Indian (Non-Spanish- 59 Vietnamese
speaking) 60 Welsh
15 Central American (i.e., Nicaraguan, 61 Yugoslavian
Guatemalan) 62 Other Asian (i.e., Thai, Laotian, Cambodian,
16 Chicano Burmese)
17 Chinese 63 Other Eastern European (i.e., Romanian,
18 Cuban Bulgarian, Albanian)
19 Czechoslovakian, Bohemian 64 Other Middle Eastern (i.e., Arabian, Saudi,
20 Danish Kuwaiti, Qatari, Syrian, Omani)
21 Dutch 65 Other Pacific Islander (i.e., Okinawan,
22 English Tahitian)
23 Filipino 66 Other South American (i.e., Chilean,
24 Finnish Columbian)
25 French 67 Other
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) Page 3 of 3