Circumcision Awareness Survey
Circumcision Awareness

1.  Are you the parent of a child (or children) under age 5?

2.  If you live in the USA, what state are you located in? If not, what country?

US State:

3.  IF you chose to circumcise any of your children, please indicate which ones below. If you did NOT, then select none.

4.  Which of the following dates describes the years in which your children under age 5 were born?
2003 (Girl)
2002 (Girl)
2001 (Girl)
2000 (Girl)
1999 (Girl)
2003 (Boy)
2002 (Boy)
2001 (Boy)
2000 (Boy)
1999 (Boy)

5.  Will you circumcise future children born to your family?

6.  Which of the following nationalities describes members of your immediate family?
African American
Native American

7.  What range does your household income fall into?

8.  Any additional comments or explanations?

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