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Module E: Demographic and Background Information

Q E-1. Are you…?

Male
Female

 

Q E-2. In what month and year were you born?

 

Q E-3. Do you identify as…? (Check one or more.)

American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latina/o
Native Hawaiian or Other Pacific Islander
White

 

Q E-4. If you are a person with a disability, what type of disability do you have? (Check all that apply.)

Blindness or Visual Impairment
Hearing Impairment
Speech or Language Impairment
Mobility or Orthopedic Impairment
Other (e.g., Specific Learning Disability, Attention Deficit Disorder, Mental Illness, or Emotional Disturbance)

 

Q E-5. What was your marital status in the fall term of the academic year 2005-06?

Single, never married
Married
Living with a companion or partner
Separated, divorced, widowed
Clear selection

 

Q E-6. During the fall term of the academic year 2005-06, did you have dependent children living with you in your home?

Yes
No

 

Q E-7. During the fall term of the academic year 2005-06, did you have one or more parents or parent(s) of a spouse or partner living with you in your home or nearby (within a radius of fifteen miles)?

No
Yes, one parent living in my home
Yes, more than one parent living in my home
Yes, one or more parents living independently nearby
Yes, one or more parents living in a nursing home or similar care facility nearby
Clear selection

 

Q E-8. During the fall term of the academic year 2005-06, was your spouse or significant other employed in a professional position at a higher education institution?

Yes, at this institution
Yes, at another higher education institution
No
Not applicable

 

Q E-9. In what country were you born?

 

Q E-10. What is your citizenship status?

United States Citizen, Native
United States Citizen, Naturalized
Permanent Resident of the United States (Immigrant Visa)
Temporary Resident of United States (Nonimmigrant Visa)
If you are not a United States citizen, select present citizenship:
Clear selection

 

Q E-11. What languages other than English do you speak or use in your academic work?

Click to select languages

 

Q E-12. What is the highest level of formal education completed by your mother and your father? What is the highest level of formal education completed by your spouse or significant other?

  Spouse or Significant Other Mother Father
PhD
Other doctoral degree (DA, EdD, etc.)
Master of Fine Arts (MFA)
Other Master's degree (MPhil, MA, MS, MBA, MEd, etc.)
First professional degree (MD, DO, DDS, JD, etc.)
Bachelor's Degree (BA, AB, BS, etc.)
Associate's Degree or equivalent (AA, AS, etc.)
Certificate or diploma for completion of undergraduate program (other than program leading to an Associate's or Bachelor's degree)
Some college (but no degree or certificate)
High school diploma
Less than high school diploma
  Clear Clear Clear

 

© 2014 Modern Language Association. Last updated 01/25/2010.