Demographics Form

We receive funding from sources that require us to ask a few questions about the people who call or visit our website. Please take a moment to give your answers to the questions below. Although it's not absolutely required, it is all kept confidential and it helps make sure that the service stays available in the future:

What is your city? (fill in the bank or refuse to answer):

What is your zip code? (fill in the blank or refuse to answer)

How many people are in your family that live together?(1-10, refuse to answer)

What's your family's (approximate) monthly income before taxes? (fill in the blank, or refuse to answer)

What is your race? (options are: Native American, Asian American, African American, Hawaiian/ Pacific Islander, White, Other, refuse to answer)

Are you Hispanic?(yes, no, refuse to answer)

What is your gender? (female, male, other, refuse to answer)

Does anybody in your family have a disability? (yes, no, refuse to answer)

Are you a single mother with kids still at home? (yes, no, refuse to answer)

If you live in housing built before 1978, did your landlord give you the blue booklet about preventing lead poisoning? (yes, no, built after 1978, refuse to answer)

*Children under 6 are especially vulnerable to lead poisoning in homes built before 1978. For more information about preventing lead poisoning, please visit www.leadline.org *