http://www.hipscc.org/programs/ltac-community-study COMMUNITY ACTIVATION/ENGAGEMENT CANVAS Question Title * 1. What is your age? 18 to 44 45 to 64 65 or older Question Title * 2. What is your gender? Female Male Question Title * 3. What is your ethnicity? Hispanic or Latino Not Hispanic or Latino Question Title * 4. What is your race? Mark one or more. American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other Question Title * 5. What is the highest level of education you have completed? 8th grade or less Some High School, but did not graduate High School Graduate or GED Some College or 2 Year Degree 4 Year College Graduate More Than 4 Year College Degree Question Title * 6. What is your current Insurance status? Medicare Medi-Cal/Alliance Medicare and Medi-Cal/Alliance Private Insurance Uninsured Question Title * 7. In what ZIP code is your home located? (enter 5-digit ZIP code; for example, 00544 or 94305) Next