Part I

 

Sex: Male Female

Age: Years

Marital Status:

Single Married Common Law Separated

Divorced Widowed Other

Number of Children:

Last grade completed in public or high school:

Level of post-secondary education:

Some university/college

Community college diploma

Undergraduate university degree

Graduate university degree

Current Occupation: Hours per week:

Total Annual Family Income:

Less than 10,000

10,000 to 19,999

20,000 to 29,999

30,000 to 39,999

40,000 plus

Cultural/racial background:

Maternal Language:

French English Other

Religious affiliation:

Catholic Protestant Jewish

Muslim Other None

Where do you live?

Canada

United States

United Kingdom

Australia

France

Indicate your country

 

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