LAHC Infant and Maternal Health Community Participants Survey

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Demographic Questions

What is your age?

18 – 24 years old

25 – 34 years old

35 – 44 years old

45 and older

Clear selection

What race/ethnicity do you consider yourself to be (You can choose more than one)

White

Black or African American

Middle Eastern or Arab American

Asian

American Indian or Alaskan Native

Native Hawaiian or Other Pacific Islander

Hispanic

Other:

What generation of American are you?

First Generation (Born in another country)

Second Generation (Have at least one parent born in another country)

Third Generation ( Both Parents born in the United States

Prefer not to answer

Other:

Clear selection

What culture or cultures best represent you? (For example: Egyptian, Lebanese, Yemeni, Pakistani, etc.…)

If you have children, how many do you have?

If you have children, what ages are they? (Select all that apply)

0 to 2 years old

3 to 5 years old

6 to 8 years old

9 to 11 years old

12 to 14 years old

15 to 17 years old

18 years or older

What stage of pregnancy are you currently at?

Planning to get pregnant within the next six months

Currently pregnant

After birth ( 0 to 6 months )

After birth ( 6 months to 1 year )

After birth ( 1 year to 3 years )

Clear selection

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy