Date Entered:___________ Staff Initials:___________

COMBINE Demographic Form (DEM ver. B)

Center Participant # Date Participant Initials Week Staff ID Sequence

0 1 /
mo. da.

/
yr.

Instructions: Note participants must be > 18 years of age to be eligible for randomization. 1. Sex: (1) Male (2) Female

2.

Date of Birth
month

/
day

/19
year

3.

Marital Status (1) Single (2) Married Race/Ethnicity

(3) Separated (4) Divorced

(5) Widow(er) (6) Cohabiting

(7) Partner

4.

(1) American Indian or Alaskan Native

Tribe:______________________________
(Specify)

(2) Asian or Asian American (3) Pacific Islander (4) Black or African American (5) Hispanic, Cuban (6) Hispanic, Mexican (7) Hispanic, New Mexican (or Spanish-American) (8) Hispanic, Puerto-Rican (9) Hispanic, Other Latin American (10) White, not of Hispanic origin

(11) Bi- or multi-racial

(12) Other ethnic group:______________________________
(Specify)

DEM_6 (04/02/02)

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Date Entered:___________ Staff Initials:___________

Center

Participant # Date

Participant Initials

Week Staff ID

Sequence

0 1 /
mo. da.

/
yr.

5.

Give participant page 3 and document origin/descent next to 5a through 5g. Here is a list of origins and descents. Please indicate origin or descent for yourself, mother, father, and grandparents

5a. Participant 5b. Mother 5c. Father 5d. Maternal Grandmother

5e. Maternal Grandfather 5f. Paternal Grandmother 5g. Paternal Grandfather

6. What is your current employment status? (check one) (1) Homemaker (if yes, also give the usual occupation of spouse)_________________________
(Specify)

(2) Disabled (usual occupation)_________________________

(Specify)

(3) Unemployed (4) Retired (5) Currently working full-time (usual occupation)_________________________
(Specify)

(6) Currently working part-time (usual occupation)_________________________

(Specify)

(7) Other_________________________
(Specify)

7. How many years of education have you completed? (GED = 12)_______ 8. What is the total yearly income, earned by all family members living in your household, before taxes (check one)? (1) Less than $15,000 (3) $30,000 - $59,999 (5) Over $90,000 (2) $15,000 - $29,999 (4) $60,000 - $89,999

DEM_6 (04/02/02)

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Date Entered:___________ Staff Initials:___________

Origin/Descent Code
01 Afghanistani 02 African (i.e. Egyptian, Nigerian, Algerian) 03 African-American (Black, Negro, or AfroAmerican) 04 Aleutian Islander 05 American Indian/Native American 06 American, NOS 07 Australian 08 Australian Aboriginal 09 Austrian 10 Belgian 11 Brazilian 12 Canadian 13 Caribbean or West Indian (Spanish-speaking) 14 Caribbean or West Indian (Non-Spanishspeaking) 15 Central American (i.e., Nicaraguan, Guatemalan) 16 Chicano 17 Chinese 18 Cuban 19 Czechoslovakian, Bohemian 20 Danish 21 Dutch 22 English 23 Filipino 24 Finnish 25 French 26 German 27 Greek 28 Guamanian 29 Hungarian 30 Indian, Afghan 31 Indonesian 32 Iranian 33 Iraqi 34 Irish 35 Israeli 36 Italian 37 Japanese 38 Jordanian 39 Korean 40 Lebanese 41 Malaysian 42 Mexican 43 Mexican-American 44 New Zealander
DEM_6 (04/02/02)

45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67

Norwegian Pakistani Polish Portuguese Puerto Rican Russian Scottish Samoan Spanish Swedish Swiss Taiwanese Torres Strait Islander Turkish Vietnamese Welsh Yugoslavian Other Asian (i.e., Thai, Laotian, Cambodian, Burmese) Other Eastern European (i.e., Romanian, Bulgarian, Albanian) Other Middle Eastern (i.e., Arabian, Saudi, Kuwaiti, Qatari, Syrian, Omani) Other Pacific Islander (i.e., Okinawan, Tahitian) Other South American (i.e., Chilean, Columbian) Other

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