AFA MemTrax Questionnaire V20181023
Section 1: General Demographics
DATE:
TIME (24hr):
WRIISC ID:
Please complete all items.
Sex (Fill in one answer):
Male
Female
Race (Fill in all that apply):
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
Unknown
Other:
Ethnicity (Fill in one answer):
Non Hispanic or Non Latino
Hispanic or Latino
Unknown
Education (Please fill in the highest year of school you completed. Fill in one answer.):
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15  16 17 18 19 20 21 22 +23
Education (Please fill in all educational degrees obtained):
High School diploma/GED
Technical/Trade School
Associate Degree
Bachelor Degree
Master's Degree
PhD/Doctorate Degree
MD
JD
Other:
Primary Language:
Secondary Language:
Living Situation (Fill in one answer):
House
Condo/Co-op (owned)
Apartment (rented)
Mobile Home
Retirement Community
Assisted Living
Skilled Nursing Facility
Other
Marital Status (Fill in one answer):
Currently Married
Widowed
Divorced
Separated
Never married
Living with a Partner
Number of years with current partner or spouse: (drop-down menu) - dem_mar_length
Number of times married: (drop-down menu) - dem_mar_times
How is your partner’s/spouse’s health? (Fill in one answer.)
Excellent
Very Good
Good
Fair
Poor
Employment Status (Fill in all that apply.):
Employed full-time
Employed part-time
Unemployed
Student
Homemaker
Retired
Applying for Disability Benefits
Receiving for Disability Benefits
Other:
What is/was the field of your primary occupation during most of your adult life:
Agriculture, Forestry, Fishing, or Hunting
Arts, Entertainment, or Recreation
Broadcasting
Education - College, University, or Adult
Education - Primary/Secondary (K-12)
Education - Other
Construction
Finance and Insurance
Government and Public Administration
Health Care and Social Assistance
Homemaker
Hotel and Food Services
Information - Services and Data
Information - Other
Processing
Legal Services
Manufacturing - Computer and Electronics
Manufacturing - Other
Military
Mining
Publishing
Real Estate, Rental, or Leasing
Religious
Retail
Scientific or Technical Services
Software
Telecommunications
Transportation and Warehousing
Utilities
Wholesale
*Other
Are you a Veteran of the Armed Forces? (Fill in one answer):
No
Yes
Please indicate which branch of the Armed Forces (Fill in one answer):
Air Force
Army
Coast Guard
Marines
National Guard
Navy
Are you right or left hand dominant?
Don't know
Right
Left
Both/Ambidextrous
Last update: 10/16/2018