Demographic Survey for PocketHealth

Instructions: We invite you to complete this optional survey to help us evaluate our diversity, equity, and inclusion efforts. Submission of the information on this form is voluntary and refusal to provide it will not subject you to adverse treatment or affect your job application. This information will be kept secure and confidential and will be used solely to evaluate our diversity and inclusion efforts. This survey should take approximately 4 minutes to complete.

• What is your age range?
  • 18 or below
  • 18-24
  • 25-34
  • 35-44
  • 45-54
  • 55-64
  • 65 and above
  • Prefer not to disclose
• How do you identify your race/ethnicity?

  Select all that apply

  • African/Black
  • Caribbean
  • Caucasian/White
  • East Asian (including Chinese, Japanese, Korean, Mongolian, Tibetan, and Taiwanese)
  • European
  • Hispanic/Latin American
  • Indigenous/Aboriginal
  • Middle Eastern/North African
  • Pacific Islander
  • South Asian (including Bangladeshi, Bhutanese, Indian, Nepali, Pakistani, and Sri Lankan)
  • Southeast Asian (including Burmese, Cambodian, Filipino, Hmong, Indonesian, Laotian, Malaysian, Mien, Singaporean, Thai, and Vietnamese)
  • Prefer not to disclose
• What gender do you identify as?

  Select all that apply

  • Agender
  • Androgynous
  • Bigender/Two-spirit
  • Non-binary/Genderqueer
  • Woman
  • Man
  • Prefer not to disclose
• Do you identify as being part of the 2SLGBTQ+ community?
  • Yes
  • No
  • Prefer not to disclose
• Do you identify as transgender?
  • Yes
  • No
  • Prefer not to disclose
• Do you identify as an individual with a disability?

  The definition of disability is very broad and always changing. We trust that you will share the answer that you best identify with.

  • Yes
  • No
  • Prefer not to disclose