Hhq-Gp-1 Healthy Heart Questionnaire - Urban Indian Heart Health Program Page 15
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15Healthy Heart Questionnaire (HHQ-GP-1)
15
85. If you marked “American Indian or Alaska Native” in the previous question, what tribe do
you most closely identify with?
___________________________________________________________
86. What is the highest grade in school you completed?
th
th
○ None
○ 5
grade
○ 10
grade
○ Some college
st
th
th
○ 1
grade
○ 6
grade
○ 11
grade
○ College graduate
○ Some graduate/professional
nd
th
th
○ 2
grade
○ 7
grade
○ 12
grade
school
○ High School
rd
th
○ 3
grade
○ 8
grade
○ Graduate/professional degree
graduate/GED
th
th
○ 4
grade
○ 9
grade
○ Vocational school
87. Please fill in the category below that best fits the total combined income before taxes of all
people who lived in your household last year. This should include not only wages, salaries,
and tips but also income from social security, pension, unemployment, or disability
compensation, alimony, child support, welfare, or any other money income received by all
household members – by you or anyone else living with you.
○ Nothing
○ $20,000 - $29,999
○ Less than $1,000
○ $30,000 - $39,999
○ $1,000 - $4,999
○ $40,000 – $49,999
○ $5,000 - $9,999
○ $50,000 - $74,999
○ $10,000 - $14,999
○ $75,000 - $99,999
○ $15,000 - $19,999
○ More than $100,000
Thank you for taking the time to fill out this survey!
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