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Pride Center Social Determinants of Health Survey 🌈
A brief 2-minute survey to connect you with better resources here in Staten Island and New York City! Funded by the Staten Island Performing Provider System (SIPPS)
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* Indicates required question
First Name
*
Your answer
Last Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Race/ Ethnicity
*
Native American/ Alaska Native
Asian
Black/ African American
Hispanic/ Latinx
Middle Eastern/ Northern African
Native Hawaiian/ Pacific Islander
White
Prefer not to say
Unknown
Other
Required
Education Level
*
Elementary school
Some high school
High School Diploma/ GED/ HSE
Some College
Associate's or technical degree
College/ Undergraduate Degree
Graduate Degree
Doctoral/ Post-graduate Degree
Unknown
Required
Employment Status
*
Employed
Not in Labor Force
Retired
Unemployed
Unknown
Required
Are you currently experiencing homelessness?
*
Yes
No
In your own words, what is your gender identity?Â
*
Your answer
Select the term(s) with which you identify, even if the same as above:
*
Cisgender man
Cisgender woman
Gender non-conforming
Non-binary
Transgender man
Transgender woman
Not listed
Required
Do you wish to be followed up with referrals for services here in New York City?
*
Yes
No
If yes, enter your email address:
Your answer
If yes, enter your phone number:
Your answer
Submit
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