Questionnaire
Part A. Tell Us About Yourself.

INSTRUCTIONS: Please answer each question by marking the best response OR by filling in the blank.

Sometimes you also will be asked to specify some other information . Some questions will ask you to check all that apply.

If you cannot or don't want to answer a question, circle the question number and move on to the next question.

Sometimes you will be directed to skip over questions that do not apply to your experience. If a question doesn't accurately describe your experience, please tell us so.

We want to know how you experience your sexuality

   A. Please tell us about yourself.

     1. Year Born (write the number in the blank to the right):_____

     2. Ethnicity:

          l usually describe my ethnicity as (circle one):

African American

Asian American

Caucasian

Latina

Native American

Other__________________________________________ 

High school

Some college

Vocational degree

2-year degree

4-year degree

Graduate work

Graduate degree

 

       5. Religion/Spirituality: The average number of times per month I attend services or other spiritual
           observances now, and did as a child is (please write the number of times):

 

 

 

 

 

       

        6. Children: The ages of the children I am raising or have raised is:

            Males _________________ Females __________________________

           (Please circle the ages of any children now living in your home.)

        7. Income:

            a. The approximate pretax income I earn per year is (circle one):

  Less than $12,000

  $12,001-$25,000

  $25,001-$50,000

  $50,001-$75,000

  $75,001-$120,000

  $120,001+