22-23 Data PPG Pre Test (4 Sessions)

Demographics

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* 1. What is your full name?

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* 2. At what email address would you like to be contacted?

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* 3. Gender:

Male

Female

Other (please specify)

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* 4. Age:

15-17

18-20

21-24

25-44

45-64

65 or older

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* 5. Race:

American Indian/Alaska Native

Asian

Black/African American

White

Pacific Islander

Multi-racial

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* 6. Ethnicity:

Haitian

Hispanic

Non-hispanic

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* 7. Home zip code:

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* 8. Primary Language:

English

Spanish

Haitian Creole

Other (please specify)

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* 9. Secondary Language:

English

Spanish

Haitian Creole

Other (please specify)

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* 10. Do you have health insurance (ex. Private Insurance, KidCare, Medicaid)?

Yes

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* 11. I am a:

Mother

Father

Adult Mentor

Grandparent

Foster Parent

Other (please specify)