U.S. Demographics Template

Question Title

* 1. In what state or U.S. territory do you live?

Alabama

Alaska

American Samoa

Arkansas

California

Colorado

Connecticut

Delaware

District of Columbia (DC)

Florida

Georgia

Guam

Hawaii

Idaho

Illinois

Indiana

Iowa

Kansas

Kentucky

Louisiana

Maine

Maryland

Massachusetts

Michigan

Minnesota

Mississippi

Missouri

Montana

Nebraska

Nevada

New Hampshire

New Jersey

New Mexico

New York

North Carolina

North Dakota

Northern Marianas Islands

Ohio

Oklahoma

Oregon

Pennsylvania

Puerto Rico

Rhode Island

South Carolina

South Dakota

Tennessee

Texas

Utah

Vermont

Virginia

Virgin Islands

Washington

West Virginia

Wisconsin

Wyoming

Question Title

* 2. Are your living quarters owned or being bought by you or someone in your household, rented for cash, or occupied without payment of cash rent?

Owned or being bought by you or someone in your household

Rented for cash

Occupied without payment of cash rent

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* 3. Are you male or female?

Male

Female

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* 4. Which category below includes your age?

17 or younger

18-20

21-29

30-39

40-49

50-59

60 or older

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* 5. Are you now married, widowed, divorced, separated, or never married?

Married

Widowed

Divorced

Separated

Never married

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* 6. What is the highest level of school you have completed or the highest degree you have received?

Less than high school degree

High school degree or equivalent (e.g., GED)

Some college but no degree

Associate degree

Bachelor degree

Graduate degree

Question Title

* 7. Are you Mexican, Mexican-American, Chicano, Puerto Rican, Cuban, Cuban-American, or some other Spanish, Hispanic, or Latino group?

I am not Spanish, Hispanic, or Latino

Mexican

Mexican-American

Chicano

Puerto Rican

Cuban

Cuban-American

Some other Spanish, Hispanic, or Latino group

From multiple Spanish, Hispanic, or Latino groups

Question Title

* 8. Are you White, Black or African-American, American Indian or Alaskan Native, Asian, Native Hawaiian or other Pacific islander, or some other race?

White

Black or African-American

American Indian or Alaskan Native

Asian

Native Hawaiian or other Pacific Islander

From multiple races

Some other race (please specify)

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* 9. Does anyone in your household own a business or a farm?

Yes

Question Title

* 10. Which of the following categories best describes your employment status?

Employed, working 1-39 hours per week

Employed, working 40 or more hours per week

Not employed, looking for work

Not employed, NOT looking for work

Retired

Disabled, not able to work

Question Title

* 11. How much total combined money did all members of your HOUSEHOLD earn in 2010? This includes money from jobs; net income from business, farm, or rent; pensions; dividends; interest; social security payments; and any other money income received by members of your HOUSEHOLD that are EIGHTEEN (18) years of age or older. Please report the total amount of money earned - do not subtract the amount you paid in taxes or any deductions listed on your tax return.

$0 - $4,999

$5,000 - $7,499

$7,500 - $9,999

$10,000 - $12,499

$12,500 - $14,999

$15,000 - $19,999

$20,000 - $24,999

$25,000 - $29,999

$30,000 - $34,999

$35,000 - $39,999

$40,000 - $49,999

$50,000 - $59,999

$60,000 - $74,999

$75,000 - $99,999

$100,000 - $149,999

$150,000 or More

Question Title

* 12. How much money did YOU personally earn in 2010? This includes money from jobs; net income from business, farm, or rent; pensions; dividends; interest; social security payments; and any other money income received by YOU. Please report the total amount of money you earned - do not subtract the amount you paid in taxes or any deductions listed on your tax return.

$0 - $9,999

$10,000 - $19,999

$20,000 - 29,999

$30,000 - $39,999

$40,000 - $49,999

$50,000 - $59,999

$60,000 - $69,999

$70,000 - $79,999

$80,000 - $89,999

$90,000 - $99,999

$100,000 or More