Date Entered:___________

Staff Initials:___________

COMBINE
Demographic Form (DEM ver. B)
Center

Participant #

Participant Initials

Week

Sequence

0 1
Date

Staff ID

mo.

da.

yr.

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

1.

Sex:

2.

Date of Birth

(2) Female

/
month

3.

4.

Marital Status
(1) Single
(2) Married

/19
day

year

(3) Separated
(4) Divorced

(5) Widow(er)
(6) Cohabiting

(7) Partner

Race/Ethnicity
(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)

Page 1

of 3

Date Entered:___________
Staff Initials:___________

Center

Participant #

Participant Initials

Week

Sequence

0 1
Date

/
mo.

5.

Staff ID

/
da.

yr.

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

5e. Maternal Grandfather

5b. Mother

5f. Paternal Grandmother

5c. Father

5g.

Paternal Grandfather

5d. Maternal Grandmother

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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