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Demographic Information Sheet-1

ICR 201305-0920-007 · OMB 0920-0915 · Object 39715101.

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Demographic Information Sheet


  1. AGE: ____________________





  1. GENDER: ________________



  1. Do you identify yourself as Hispanic or Latino?

  1. Yes, Hispanic or Latino

  2. No, Not of Hispanic or Latino Origin

  3. Refused



  1. Which of these groups best identifies your race? (Please select all that apply)

  1. American Indian or Alaska Native

  2. Asian

  3. Black or African-American

  4. Native Hawaiian or Other Pacific Islander

  5. White/Caucasian

  6. Refuse to answer



  1. EMPLOYMENT STATUS ( please circle the answer that best describes you):

  1. Employed full-time

  2. Employed part-time

  3. Not currently employed

  4. Retired

  5. Student



  1. What type of SCD have you been diagnosed with? _____________________________





  1. Do you receive care at a Comprehensive SCD Center( please circle the answer that best describes you?



  1. Yes

  2. No







File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title Demographic Information Sheet-1
AuthorCDC User
File Modified0000-00-00
File Created2021-01-29