Adult Participant Demographic Survey
Author: Amy Breese
Keywords: SRAE
Description: SRAE Online Reporting System:This brief survey can be distributed to adult (parent/caregiver) participants to collect information about age, gender, race, and ethnicity. Each page in this document can be cut in half to yield two surveys, and the number in the upper right hand corner of each may be used as the participant ID. Though collection of this information is required, use of this tool is optional.The document is provided here in Publisher format so that it can be modified to suit your needs.

ADULT SURVEY: PID 1

ADULT SURVEY: PID 2

What group are you with?

What group are you with?

Directions: Please circle or fill in your answers for each question.

Directions: Please circle or fill in your answers for each question.

What is your name? _________________________

What is your name? _________________________

Role:
Parent/caregiver
Other adult

Role:
Parent/caregiver
Other adult

Gender:

Male
Female
Trans and/or gender non-conforming
None of the above

Gender:

Male
Female
Trans and/or gender non-conforming
None of the above

Ethnicity and Race (mark all that apply):

Ethnicity and Race (mark all that apply):

Latino/a
White
Black
Asian
Native American/Alaska Native
Native Hawaiian/Other Pacific Islander
Other

Latino/a
White
Black
Asian
Native American/Alaska Native
Native Hawaiian/Other Pacific Islander
Other

Thanks for being part of this program!

Thanks for being part of this program!

ADULT SURVEY PID 3

ADULT SURVEY PID 4

What group are you with?

What group are you with?

Directions: Please circle or fill in your answers for each question.

Directions: Please circle or fill in your answers for each question.

What is your name? _________________________

What is your name? _________________________

Role:
Parent/caregiver
Other adult

Role:
Parent/caregiver
Other adult

Gender:

Male
Female
Trans and/or gender non-conforming
None of the above

Gender:

Male
Female
Trans and/or gender non-conforming
None of the above

Ethnicity and Race (mark all that apply):

Ethnicity and Race (mark all that apply):

Latino/a
White
Black
Asian
Native American/Alaska Native
Native Hawaiian/Other Pacific Islander
Other

Latino/a
White
Black
Asian
Native American/Alaska Native
Native Hawaiian/Other Pacific Islander
Other

Thanks for being part of this program!

Thanks for being part of this program!

ADULT SURVEY PID 5

ADULT SURVEY PID 6

What group are you with?

What group are you with?

Directions: Please circle or fill in your answers for each question.

Directions: Please circle or fill in your answers for each question.

What is your name? _________________________

What is your name? _________________________

Role:
Parent/caregiver
Other adult

Role:
Parent/caregiver
Other adult

Gender:

Male
Female
Trans and/or gender non-conforming
None of the above

Gender:

Male
Female
Trans and/or gender non-conforming
None of the above

Ethnicity and Race (mark all that apply):

Ethnicity and Race (mark all that apply):

Latino/a
White
Black
Asian
Native American/Alaska Native
Native Hawaiian/Other Pacific Islander
Other

Latino/a
White
Black
Asian
Native American/Alaska Native
Native Hawaiian/Other Pacific Islander
Other

Thanks for being part of this program!

Thanks for being part of this program!

ADULT SURVEY PID 7

ADULT SURVEY PID 8

What group are you with?

What group are you with?

Directions: Please circle or fill in your answers for each question.

Directions: Please circle or fill in your answers for each question.

What is your name? _________________________

What is your name? _________________________

Role:
Parent/caregiver
Other adult

Role:
Parent/caregiver
Other adult

Gender:

Male
Female
Trans and/or gender non-conforming
None of the above

Gender:

Male
Female
Trans and/or gender non-conforming
None of the above

Ethnicity and Race (mark all that apply):

Ethnicity and Race (mark all that apply):

Latino/a
White
Black
Asian
Native American/Alaska Native
Native Hawaiian/Other Pacific Islander
Other

Latino/a
White
Black
Asian
Native American/Alaska Native
Native Hawaiian/Other Pacific Islander
Other

Thanks for being part of this program!

Thanks for being part of this program!

ADULT SURVEY PID 9

ADULT SURVEY PID 10

What group are you with?

What group are you with?

Directions: Please circle or fill in your answers for each question.

Directions: Please circle or fill in your answers for each question.

What is your name? _________________________

What is your name? _________________________

Role:
Parent/caregiver
Other adult

Role:
Parent/caregiver
Other adult

Gender:

Male
Female
Trans and/or gender non-conforming
None of the above

Gender:

Male
Female
Trans and/or gender non-conforming
None of the above

Ethnicity and Race (mark all that apply):

Ethnicity and Race (mark all that apply):

Latino/a
White
Black
Asian
Native American/Alaska Native
Native Hawaiian/Other Pacific Islander
Other

Latino/a
White
Black
Asian
Native American/Alaska Native
Native Hawaiian/Other Pacific Islander
Other

Thanks for being part of this program!

Thanks for being part of this program!

ADULT SURVEY PID 11

ADULT SURVEY PID 12

What group are you with?

What group are you with?

Directions: Please circle or fill in your answers for each question.

Directions: Please circle or fill in your answers for each question.

What is your name? _________________________

What is your name? _________________________

Role:
Parent/caregiver
Other adult

Role:
Parent/caregiver
Other adult

Gender:

Male
Female
Trans and/or gender non-conforming
None of the above

Gender:

Male
Female
Trans and/or gender non-conforming
None of the above

Ethnicity and Race (mark all that apply):

Ethnicity and Race (mark all that apply):

Latino/a
White
Black
Asian
Native American/Alaska Native
Native Hawaiian/Other Pacific Islander
Other

Latino/a
White
Black
Asian
Native American/Alaska Native
Native Hawaiian/Other Pacific Islander
Other

Thanks for being part of this program!

Thanks for being part of this program!

ADULT SURVEY PID 13

ADULT SURVEY PID 14

What group are you with?

What group are you with?

Directions: Please circle or fill in your answers for each question.

Directions: Please circle or fill in your answers for each question.

What is your name? _________________________

What is your name? _________________________

Role:
Parent/caregiver
Other adult

Role:
Parent/caregiver
Other adult

Gender:

Male
Female
Trans and/or gender non-conforming
None of the above

Gender:

Male
Female
Trans and/or gender non-conforming
None of the above

Ethnicity and Race (mark all that apply):

Ethnicity and Race (mark all that apply):

Latino/a
White
Black
Asian
Native American/Alaska Native
Native Hawaiian/Other Pacific Islander
Other

Latino/a
White
Black
Asian
Native American/Alaska Native
Native Hawaiian/Other Pacific Islander
Other

Thanks for being part of this program!

Thanks for being part of this program!

ADULT SURVEY PID 15

ADULT SURVEY PID 16

What group are you with?

What group are you with?

Directions: Please circle or fill in your answers for each question.

Directions: Please circle or fill in your answers for each question.

What is your name? _________________________

What is your name? _________________________

Role:
Parent/caregiver
Other adult

Role:
Parent/caregiver
Other adult

Gender:

Male
Female
Trans and/or gender non-conforming
None of the above

Gender:

Male
Female
Trans and/or gender non-conforming
None of the above

Ethnicity and Race (mark all that apply):

Ethnicity and Race (mark all that apply):

Latino/a
White
Black
Asian
Native American/Alaska Native
Native Hawaiian/Other Pacific Islander
Other

Latino/a
White
Black
Asian
Native American/Alaska Native
Native Hawaiian/Other Pacific Islander
Other

Thanks for being part of this program!

Thanks for being part of this program!

ADULT SURVEY PID 17

ADULT SURVEY PID 18

What group are you with?

What group are you with?

Directions: Please circle or fill in your answers for each question.

Directions: Please circle or fill in your answers for each question.

What is your name? _________________________

What is your name? _________________________

Role:
Parent/caregiver
Other adult

Role:
Parent/caregiver
Other adult

Gender:

Male
Female
Trans and/or gender non-conforming
None of the above

Gender:

Male
Female
Trans and/or gender non-conforming
None of the above

Ethnicity and Race (mark all that apply):

Ethnicity and Race (mark all that apply):

Latino/a
White
Black
Asian
Native American/Alaska Native
Native Hawaiian/Other Pacific Islander
Other

Latino/a
White
Black
Asian
Native American/Alaska Native
Native Hawaiian/Other Pacific Islander
Other

Thanks for being part of this program!

Thanks for being part of this program!

ADULT SURVEY PID 19

ADULT SURVEY PID 20

What group are you with?

What group are you with?

Directions: Please circle or fill in your answers for each question.

Directions: Please circle or fill in your answers for each question.

What is your name? _________________________

What is your name? _________________________

Role:
Parent/caregiver
Other adult

Role:
Parent/caregiver
Other adult

Gender:

Male
Female
Trans and/or gender non-conforming
None of the above

Gender:

Male
Female
Trans and/or gender non-conforming
None of the above

Ethnicity and Race (mark all that apply):

Ethnicity and Race (mark all that apply):

Latino/a
White
Black
Asian
Native American/Alaska Native
Native Hawaiian/Other Pacific Islander
Other

Latino/a
White
Black
Asian
Native American/Alaska Native
Native Hawaiian/Other Pacific Islander
Other

Thanks for being part of this program!

Thanks for being part of this program!

ADULT SURVEY PID 21

ADULT SURVEY PID 22

What group are you with?

What group are you with?

Directions: Please circle or fill in your answers for each question.

Directions: Please circle or fill in your answers for each question.

What is your name? _________________________

What is your name? _________________________

Role:
Parent/caregiver
Other adult

Role:
Parent/caregiver
Other adult

Gender:

Male
Female
Trans and/or gender non-conforming
None of the above

Gender:

Male
Female
Trans and/or gender non-conforming
None of the above

Ethnicity and Race (mark all that apply):

Ethnicity and Race (mark all that apply):

Latino/a
White
Black
Asian
Native American/Alaska Native
Native Hawaiian/Other Pacific Islander
Other

Latino/a
White
Black
Asian
Native American/Alaska Native
Native Hawaiian/Other Pacific Islander
Other

Thanks for being part of this program!

Thanks for being part of this program!

ADULT SURVEY PID 23

ADULT SURVEY PID 24

What group are you with?

What group are you with?

Directions: Please circle or fill in your answers for each question.

Directions: Please circle or fill in your answers for each question.

What is your name? _________________________

What is your name? _________________________

Role:
Parent/caregiver
Other adult

Role:
Parent/caregiver
Other adult

Gender:

Male
Female
Trans and/or gender non-conforming
None of the above

Gender:

Male
Female
Trans and/or gender non-conforming
None of the above

Ethnicity and Race (mark all that apply):

Ethnicity and Race (mark all that apply):

Latino/a
White
Black
Asian
Native American/Alaska Native
Native Hawaiian/Other Pacific Islander
Other

Latino/a
White
Black
Asian
Native American/Alaska Native
Native Hawaiian/Other Pacific Islander
Other

Thanks for being part of this program!

Thanks for being part of this program!

ADULT SURVEY PID 25

ADULT SURVEY PID 26

What group are you with?

What group are you with?

Directions: Please circle or fill in your answers for each question.

Directions: Please circle or fill in your answers for each question.

What is your name? _________________________

What is your name? _________________________

Role:
Parent/caregiver
Other adult

Role:
Parent/caregiver
Other adult

Gender:

Male
Female
Trans and/or gender non-conforming
None of the above

Gender:

Male
Female
Trans and/or gender non-conforming
None of the above

Ethnicity and Race (mark all that apply):

Ethnicity and Race (mark all that apply):

Latino/a
White
Black
Asian
Native American/Alaska Native
Native Hawaiian/Other Pacific Islander
Other

Latino/a
White
Black
Asian
Native American/Alaska Native
Native Hawaiian/Other Pacific Islander
Other

Thanks for being part of this program!

Thanks for being part of this program!

ADULT SURVEY PID 27

ADULT SURVEY PID 28

What group are you with?

What group are you with?

Directions: Please circle or fill in your answers for each question.

Directions: Please circle or fill in your answers for each question.

What is your name? _________________________

What is your name? _________________________

Role:
Parent/caregiver
Other adult

Role:
Parent/caregiver
Other adult

Gender:

Male
Female
Trans and/or gender non-conforming
None of the above

Gender:

Male
Female
Trans and/or gender non-conforming
None of the above

Ethnicity and Race (mark all that apply):

Ethnicity and Race (mark all that apply):

Latino/a
White
Black
Asian
Native American/Alaska Native
Native Hawaiian/Other Pacific Islander
Other

Latino/a
White
Black
Asian
Native American/Alaska Native
Native Hawaiian/Other Pacific Islander
Other

Thanks for being part of this program!

Thanks for being part of this program!

ADULT SURVEY PID 29

ADULT SURVEY PID 30

What group are you with?

What group are you with?

Directions: Please circle or fill in your answers for each question.

Directions: Please circle or fill in your answers for each question.

What is your name? _________________________

What is your name? _________________________

Role:
Parent/caregiver
Other adult

Role:
Parent/caregiver
Other adult

Gender:

Male
Female
Trans and/or gender non-conforming
None of the above

Gender:

Male
Female
Trans and/or gender non-conforming
None of the above

Ethnicity and Race (mark all that apply):

Ethnicity and Race (mark all that apply):

Latino/a
White
Black
Asian
Native American/Alaska Native
Native Hawaiian/Other Pacific Islander
Other

Latino/a
White
Black
Asian
Native American/Alaska Native
Native Hawaiian/Other Pacific Islander
Other

Thanks for being part of this program!

Thanks for being part of this program!

ADULT SURVEY PID

ADULT SURVEY PID

What group are you with?

What group are you with?

Directions: Please circle or fill in your answers for each question.

Directions: Please circle or fill in your answers for each question.

What is your name? _________________________

What is your name? _________________________

Role:
Parent/caregiver
Other adult

Role:
Parent/caregiver
Other adult

Gender:

Male
Female
Trans and/or gender non-conforming
None of the above

Gender:

Male
Female
Trans and/or gender non-conforming
None of the above

Ethnicity and Race (mark all that apply):

Ethnicity and Race (mark all that apply):

Latino/a
White
Black
Asian
Native American/Alaska Native
Native Hawaiian/Other Pacific Islander
Other

Latino/a
White
Black
Asian
Native American/Alaska Native
Native Hawaiian/Other Pacific Islander
Other

Thanks for being part of this program!

Thanks for being part of this program!