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From Persecution to Prison - Bellevue/NYU Program for Survivors of ...

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18. Country from which fleeing persecution (specify only if different from nationality)19. Race (circle one):Black . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Caucasian . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2Latino/Hispanic . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .420. Ethnicity / Tribal group21. Religion:Buddhist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Jewish . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2Christian . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3Muslim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4Hindu . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5None . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .722. Highest level <strong>of</strong> education attained: (Circle one)None . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Primary School . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2Some high school/secondary School course Work . . . .3High School/Secondary School graduate Degree . . . . .4Some college vocational course work . . . . . . . . . . . . .5College/vocational degree . . . . . . . . . . . . . . . . . . . . . .6Graduate Pr<strong>of</strong>essional training (beyond college) . . . . .7Graduate/pr<strong>of</strong>essional degree (ex. M.D., J.D., Ph.D.) .823. Primary occupation in his/her native country:Student . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Monk/nun (religious figure) . . . . . . . . . . . . . . . . . . . .2Physician . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3Other health pr<strong>of</strong>essional . . . . . . . . . . . . . . . . . . . . . .4Lawyer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5Journalist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6Government Employee (non-military/police.) . . . . . . .7Police/Military . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8Farmer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9Housewife . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10Service Sec<strong>to</strong>r (example: taxi driver, shopkeeper) . . .11Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1224. Marital statusSingle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Married . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2Divorced . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3Widowed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4(Specify)(Specify)(Specify)(Specify)(Specify)(Specify)(Specify)204 FROM PERSECUTION TO PRISON

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