1. What is your Marital
Status?
Click here to respond.
I have never been married.
I am currently in my first marriage.
I am divorced.
I am widowed.
I am remarried.
I am separated.
2. How long have you been
married
(total number of years)?
"0" if never married.
3. How many children do you
have?
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I have no children.
I have one child.
I have two children.
I have three children.
I have four children.
I have 5 children.
I have more than five children.
4. What is your own income?
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I have no personal income.
Less than $15,000.
Between $15,000 and $20,000.
Between $20,000 and $35,000
Between $35,000 and $50,000.
Over $50,000.
5. What is your spouse's income?
Click here to respond.
My spouse has no personal income.
Less than $15,000.
Between $15,000 and $20,000.
Between $20,000 and $35,000
Between $35,000 and $50,000.
Over $50,000.
I have no spouse.
6. What is your gender?
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Male
Female
7. What is your ethnic
heritage?
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Black/African.
White non-Hispanic.
Hispanic.
Asian.
Native American
Other.
8. What is your religious
heritage?
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Protestant.
Catholic.
Jewish.
None.
Other.
9. What is your age?
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Less than 15.
15 to 18 years of age.
19 to 21 years of age
22 to 25 years of age.
26-30.
31-39.
40-49.
50-59.
60-69.
70 or older.
10. What is your spouse's age?
Click here to respond.
Less than 15.
15-18 years of age.
19 to 21 years of age
22 to 25 years of age.
26-30.
31-39.
40-49.
50-59.
60-69.
70 or older.
11. Are you
a student?
Click here to respond.
YES, a high school student.
YES, a college student.
YES, some other educational program.
NO.
12. How large is the place where you
live?
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A small town or village of less than 500.
A town of 500 to 10,000.
A town of 10,000 to 50,000.
A city of 50,000 to 200,000.
A city of 200,000 to 500,000.
A city of 500,000 to One milliion.
A city of more than One Million.
13. How frequently do you attend
church?
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I do not attend.
Less than once a month.
Less than once a week, more than once a month.
Once a week or more.
14. What is your current living
arrangement?
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Rent a house.
Rent an apartment.
Live with parents.
Other.
Live in own house.
Live in own condo.
15. Are your parents
divorced?
Click here to respond.
YES.
NO.
16. What is your level of
education?
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High School.
Trade school/Some College.
College Degree.
Advanced/Graduate Degree.
17. What is your spouse's level of
education?
Click here to respond.
High School.
Trade school/Some College.
College Degree.
Advanced/Graduate Degree.
I have no spouse.
18. How old are you (number of
years)?
optional.
19. What is your Race / Ethnicity?
optional.
20. In what country do you
live (e.g., USA)?
21. Are you
employed?
Click here to respond.
YES.
NO.
22. Do you
drive for your living?
(truck, taxi, bus driver)?
Click here to respond.
YES.
NO.
23. How
many miles per day
do you usually drive?
24. How
many driving tickets have
you received in your lifetime?
25. How
many auto accidents have
you had in your lifetime?