HeartsNParks Community Mobilization Guide - National Heart, Lung ...

A-52 Adult
✔
Please tell us a little
about yourself.
Check the correct box!
1. Your gender: ❑ 1 - Male ❑ 2 - Female
2. What is your age group?
❑ 1 - Under 21
❑ 2 - 21 – 30
❑ 3 - 31 – 40
❑ 4 - 41 – 50
❑ 5 - 51 – 60
❑ 6 - 61 – 70
❑ 7 - Over 70
3. Are you...
❑ 1 - White
❑ 2 - African American or Black
❑ 3 - Hispanic
❑ 4 - Asian or Pacific Islander
❑ 5 - American Indian or Alaska Native
❑ 6 - Other (specify: _______________ )?
4. What is your highest level of education?
❑ 1 - Less than High School
❑ 2 - High School Graduate
❑ 3 - Some College
❑ 4 - College Degree
❑ 5 - Some Graduate School
❑ 6 - Graduate Degree