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Race Questionnaire- Part 1:

For this study being conducted, you will be asked a series of questions on your preferences
involving racial matters. The goal of this survey is to gauge the racial preferences one may or
may not have based on ones own racial background. For multiple choice questions, circle the
answer that most closely relates to you. If in the multiple choice questions, you find yourself not
relating to any of the choices, circle the other option and fill in your answer. For fill in the blank
questions, answer the question to the best of your ability.
1. What is your current age? ____________
2. What is your gender?
a. Male
b. Female
c. Other: ______________________________________
3. What religion do you currently practice?
a. Christianity
b. Judaism
c. Muslim
d. Buddhism
e. Atheist
f. Other: _________________________________________
4. How would you identity your race?
a. White/Caucasian
b. African American/Black
c. Asian
d. American Indian or Alaska Native
e. Native Hawaiian or Other Pacific Islander
f. Other: _______________________________________
5. How would you identify your ethnicity? ______________________________________
6. How would you identify your nationality?
a. European
i. Name country/countries of ancestors: _____________________________
___________________________________________________________
b. Asian
i. Name country/countries of ancestors: _____________________________
____________________________________________________________
c. African
i. Name country/countries of ancestors: _____________________________
____________________________________________________________
d. North American (besides the United States; Mexican or Canadian)
i. Name country/countries of ancestors: _____________________________
____________________________________________________________

e. South American/Central America


i. Name country/countries of ancestors: _____________________________
____________________________________________________________
f. Australian
7. What is your country of birth? ____________________________________________
a. If not born in the United States, how long have you been living in the U.S.?
_______________________________________________________________

Part 2:
For this next part of the questionnaire, we will provide you with 5 different race or ethnic groups.
We will then ask you a question with multiple parts. Then, you will answer each part of the
question by rating your answer with the scale degrees 1 through 5 that we provide for you. Fill
out the chart with your responses. We will provide an example.
Question: Would you accept a person from group __ as a person who is:
1. Married to someone in my family, whether immediate family (brothers, sisters, parents)
or extended family (uncles and aunts, cousin, grandparents)
2. A close friend
3. As a co-worker
4. As a citizen of my country
5. As a person to be excluded from my country
Example:
White
Asian
African
American/Black
American
Indian/Native
American
Mexican

For Group One, I checked off boxes 1 and 4. This means that I would be accept someone from
this group as being married to someone from my family and I would accept them as a citizen in
my country. By not checking off boxes 2 and 3, it means that I would not accept someone from
this group as a close friend or as a co-worker. By not checking off box 5, I would not wish that a
person from this group should be excluded from my country. For Group 3, I only checked off
box 5. This means that I would want someone from this group to be excluded from my country. I

would not accept them as marries to someone in my family, a close friend, a co-worker, or as a
citizen of my country.

Now you fill out this chart with your own answers:
1
Married to
someone in
my family
White
Asian
African
American/Black
American
Indian/Native
American
Mexican

2
A close
friend

3
As a
coworker

4
As a citizen
of my
country

5
As a person
to be
excluded
from my
country