Health Equity Survey

Section 1

Please answer the following questions by putting the number of household members that fit in each category. If the number of household members is zero, then the category can be left blank.
Age Brackets
How many people in your family are...
Children: 0-12
Teens: 13-18
Young Adults: 19-24
Adults: 25-59
Seniors: 60+
 
Gender
Man
Woman
Other
 
Gender Identity
How many of your household members identify as transgender, nonbinary, or gender non-conforming?
 
LGBTQ+
How many of your household members identify as a member of the LGBTQ+ community?
 
Race
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Biracial
Other
 
Ethnicity
Hispanic or Latino or Spanish Origin
Not Hispanic or Latino or Spanish Origin
Don't Know
 
Diet Related Chronic Conditions
How many household members have...
Cardiovascular Disease
Diabetes
Gastrointestinal Conditions (ex. Crohn’s disease, IBS, ulcerative colitis, etc.)
High Cholesterol
Hypertension
Other
 
Other Categories
How many household members are...
Immigrants to the US
Multilingual
Veterans or Active Service Members
Physically Disabled
Identify as having a Mental Health Condition
 

Section 2

Please select one answer for each question in this section.
Employment Status
Of all able to work in your household, how many are employed?
Educational Attainment
Highest level of educational attainment in your household
Food Security
Which of these statements best describes the food eaten in your household in the last 3 months:
Acquiring Balanced Meals
How frequently has your household struggle to afford nutritionally balanced meals in the last 3 months?
SNAP Participation
Does anyone in your household receive benefits from the Supplemental Nutrition Assistance Program (SNAP), also known as food stamps?
Government Nutrition Programs
Does anyone in your household participate in government nutrition programs other than SNAP, such as the Women, Infants, and Children's Program (WIC) or the National School Lunch Program (free or reduced school lunch)?

Section 3

This section is optional. Please write a short answer for each question in this section.
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