PCS3 Socioeconomic Status Questionnaire 1

1. How many people (NOT including yourself) live in your home? ____________

2. How many bedrooms (including guest bedrooms, bedrooms used as offices etc) are in
the house or apartment which is your PRIMARY residence? ____________
____________have no primary residence

3. Which of the following best describes the highest level of educational you have
completed?

o Didn’t Finish High School

o Didn’t Finish High School, but completed a technical/vocational program
o High School Graduate or GED (General Education Diploma)
o Completed High School and a technical/vocational program
o Less than 2 Years of College
o 2 Years of College or more/ including associate degree or equivalent
o College graduate (4 or 5 year program)
o Master’s degree (or other post-graduate training)
o Doctoral degree (PhD., MD, EdD, DVM, DDS, JD, etc)

Do you have firm plans for further education? Yes____ No____

If yes, what? __________________________

4. What is your current employment status? Check ALL that apply.

o Working full time for pay → number of hours per week ________
o Working part time for pay → number of hours per week ________
o Not currently employed, looking for work
o Retired
o Homemaker
o Disabled (not working because of permanent or temporary disability)
o Other (please specify): _____________
 PCS3 Socioeconomic Status Questionnaire 2

5. Which category best describes your yearly household income before taxes? Do not
give the dollar amount, just give the category. Include all income received from
employment, social security, support from children or other family, welfare, Aid to
Families with Dependent Children (AFDC), bank interest, retirement accounts, rental
property, investments, etc.

o Less than $5,000

o $5,000 - $9,999
o $10,000 - $14,999
o $15,000 - $19,999
o $20,000 - $29,999
o $30,000 - $39,999
o $40,000 - $49,999
o $50,000 - $59,999
o $60-000 - $74,999
o $75,000 - $99,999
o $100,000 - $124,999
o $125,000 - $149,999
o $150,000 or more

6. Do you OWN your own home now (includes paying a mortgage)?

Yes____ No____

7. Do you OWN a working motor vehicle (car, truck, van, SUV) now?

Yes____ No____ If yes, how many do you own? _____

8. During the last year, did you take an out-of-town vacation?

Yes____ No____

9. Do you have a daily newspaper delivered to your home?

Yes____ No____