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First Name
Last Name
Email Address
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Mailing Address
City
State
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More About You
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about why we ask for gender, birth date, marital status, education, employment and race.)
Gender
Male
Female
Date of Birth
Month
January
February
March
April
May
June
July
August
September
October
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Day
01
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19
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31
Year
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1927
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1925
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1921
1920
Are you from Spanish, Hispanic or Latino origin or descent?
Yes
No
In what country were you born?
Select One
United States
Argentina
Belize
Bolivia
Brazil
Chile
Colombia
Costa Rica
Cuba
Dominican Republic
Ecuador
El Salvador
Guatemala
Honduras
Mexico
Nicaragua
Panama
Paraguay
Peru
Puerto Rico
Spain
Uruguay
Venezuela
Other
How long have you been living in the United States?
Select One
Born in US
Less than 10 years
10 Years or more
When at home, do you speak…
Select One
Spanish all the time
Spanish more than half of the time
Spanish and English equally
English more than half of the time
English all the time
Do you consider yourself…?
Select One
American, not Hispanic or Latino
American first, Hispanic or Latino second
Hispanic or Latino and American equally
Hispanic or Latino first, American second
Hispanic or Latino, not American
In what language do you usually watch TV?
Select One
Only Spanish
Spanish more than English
Spanish and English equally
English more than Spanish
Only English
What do you consider to be your primary country of descent or ethnic background?
Select One
Argentina
Bolivia
Brazil
Chile
Colombia
Costa Rica
Cuba
Dominican Republic
Ecuador
El Salvador
Guatemala
Honduras
Mexico
Nicaragua
Panama
Paraguay
Perú
Puerto Rico
Spain
Uruguay
Venezuela
Belize
Other
What is your country of origin? We would like to know the country or countries from which your Hispanic or Latino roots originate.
Argentina
Bolivia
Brazil
Chile
Colombia
Costa Rica
Cuba
Dominican Republic
Ecuador
El Salvador
Guatemala
Honduras
Mexico
Nicaragua
Panama
Paraguay
Peru
Puerto Rico
Spain
Uruguay
Venezuela
Belize
Other
What is your race?
Select One
White/Caucasian
Black or African-American
Asian
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Other
Prefer not to answer
What is your current marital status?
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Never Married / Single
Living with partner
Married
Separated
Divorced
Widowed
Highest level of education you have completed
Select One
Grade School
Some High School
Graduated High School or GED
Some College - no degree
Technical School or Vocational Training
Graduated College - Associate's degree
Graduated College - Bachelor's degree
Post Graduate Degree - MS, MA, MBA, MD, DVM, DDS, etc.
Doctorate - Ph.D.
Employment Status
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In permanent full-time employment
In permanent part-time employment
Self-employed / Freelance
Retired
Student, in school or apprenticeship
House wife / House husband
Unable to work / disabled
Without work OR currently not working and looking for work
Temporary, seasonal or occasional work
In unpaid employment (e.g. voluntary work) or full time care of other household member
Are you the person in your household who is primarily responsible for the grocery shopping?
Select One
Yes, I do most of the shopping for the household
Equally shared with another person in the household
No, I do not do the majority of shopping for the household
Household Information
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about why we collect information about your household.)
Including yourself, how many people live in your household?
Select One
1 (myself)
2
3
4
5
6
7
8
9
10
11
12
13
14
15 or more
What is your household's combined yearly income before taxes?
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about why we ask about income.)
Select One
Less than $10,000
$10,000 to $14,999
$15,000 to $19,999
$20,000 to $24,999
$25,000 to $29,999
$30,000 to $34,999
$35,000 to $39,999
$40,000 to $49,999
$50,000 to $59,999
$60,000 to $74,999
$75,000 to $99,999
$100,000 to $124,999
$125,000 to $149,999
$150,000 to $199,999
$200,000 or more
Prefer not to answer
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