DEMOGRAPHICS QUESTIONNAIRE

[Pages:1]DEMOGRAPHICS QUESTIONNAIRE

One of RACC's goals is to cultivate diversity, equity and inclusion in all of our programs and services. We are

working to collect demographic information about our constituents, including volunteers and apprentices,

in order to create a baseline for who we serve and to identify gaps in our services. Please help us by

indicating how you identify, checking ALL that apply and being as specific as needed in the lines

provided.

Age

Zipcode of residence:

Racial/ethnic identity

0-17

African American or Black ___________________ 18-25

___________________________

African _____________________________________ 26-35

Arab ________________________________________ 36-45 Asian _______________________________________ 46-55

What is your preferred language?

Caucasian or European descent ______________ 56-65 East Indian _________________________________ 66+

___________________________

Latina/Latino or Hispanic ___________________ Native American or Alaska Native ____________ Native Hawaiian or Pacific Islander __________ Slavic _______________________________________ Other (Please specify) _______________________

Gender Female Male Transgender Self-identify__________________

FOR OFFICE USE ONLY:

I respectfully decline to answer any of these questions

Committee/Program: Date collected:

Last updated: 7/2014

DEMOGRAPHICS QUESTIONNAIRE

One of RACC's goals is to cultivate diversity, equity and inclusion in all of our programs and services. We are

working to collect demographic information about our constituents, including volunteers and apprentices,

in order to create a baseline for who we serve and to identify gaps in our services. Please help us by

indicating how you identify, checking ALL that apply and being as specific as needed in the lines

provided.

Age

Zipcode of residence:

Racial/ethnic identity

0-17

African American or Black ___________________ 18-25

___________________________

African _____________________________________ 26-35

Arab ________________________________________ 36-45 Asian _______________________________________ 46-55

What is your preferred language?

Caucasian or European descent ______________ 56-65 East Indian _________________________________ 66+

___________________________

Latina/Latino or Hispanic ___________________ Native American or Alaska Native ____________ Native Hawaiian or Pacific Islander __________ Slavic _______________________________________ Other (Please specify) _______________________

Gender Female Male Transgender Self-identify__________________

FOR OFFICE USE ONLY:

I respectfully decline to answer any of these questions

Committee/Program:

Date collected:

Last updated: 7/2014

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