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	Part I: Participant Information

	Directions: Mark the response that represents best your response to each item. There are no right or wrong answers, so please be candid and try not to let your response to one item influence your response to other items. Be sure to answer each item. Data will be used for the sole purpose of reporting to the funding agency.

What is your gender?

Male

Female

2.	In which state are you currently employed?

Which of the following categories best describes your race/ethnicity?

White/Caucasian

Black/African American

Asian or Pacific Islander

American Indian or Alaskan Native

Other, please specify

Including this calendar year, how many total years have you worked in your current employment agency?

0-5

6-10

11-15

16-20

21-more

Which of the following categories best describes the geographic region in which you work most often?

Urban / Inner City

Suburban / Metropolis

Rural / Sparsely populated

Including this calendar year, how many total years have you worked in community/public health?

0-5

6-10

11-15

16-20

21-more