Basic demographic questionnaire template

Dear Sir / Madam,

If you would take the time to fill out this short demographic survey, we hope to use the data collected to better understand and therefore serve you as a citizen better in future.

1. Are you male or female?

  • Male
  • Female

2. Which category best represents your age?

  • 17 or younger
  • 18-20
  • 21-29
  • 30-39
  • 40-49
  • 50-59
  • 60 or older

3. What is your marital status?

  • Married
  • Widowed
  • Divorced
  • Separated
  • Never married

4. In what state or territory do you live?

500

5. In what ZIP code is your home located?

Enter 5-digit ZIP code; for example, 00544 or 94305

500

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
  • Some college but no degree
  • Associate degree
  • Bachelor degree
  • Graduate degree
  • No degree or higher education

7. Does anyone in your household own a small business or farm?

  • Yes
  • No

8. 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 and/or not able to work

9. What was your Net income in the last year?

This includes working income; income from business, rental income; pensions; dividends; interest; social security income; Please report the total amount of money you earned - do not subtract the amount

  • $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

10. What was your Net Household income in the last year?

This includes working income; Business income, Rental income; pensions; dividends; interest; social security income; and all other monetary income received by taxpaying adult members of your household

  • $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

11. Are you Mexican, Mexican-American, Chicano, Puerto Rican, Cuban, Cuban-American, Hispanic, Latino or other Spanish denomination?

  • 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

12. Are you White, Black or African-American, American Indian or Alaskan Native, Asian, Native Hawaiian / Pacific islander or other?

  • White
  • Black or African-American
  • American Indian or Alaskan Native
  • Asian
  • Native Hawaiian or other Pacific Islander
  • From multiple races

13. What are your current living conditions?

  • Owned or being bought by you or someone in your household
  • Mortgaged
  • Rented
  • Occupied without payment of rent

14. How many children age 17 below live in your household?

500

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