1. Are you the parent of a child (or children) under age 5? Choose One Yes No 2. If you live in the USA, what state are you located in? If not, what country? Country: US State: Choose One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming 3. IF you chose to circumcise any of your children, please indicate which ones below. If you did NOT, then select none. Choose One All boys. All girls. All boys and girls. None. Older boys but not younger boys. Younger boys but not older boys. Older girls but not younger girls. Younger girls but not older girls. None of the above. 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? Choose One Yes No 6. Which of the following nationalities describes members of your immediate family?White Hispanic African American Asian Native American Other 7. What range does your household income fall into? Choose One $0 - $20,000 $20,000 - $30,000 $30,000 - $40,000 $40,000 - $50,000 $50,000 - $60,000 $60,000 - $75,000 $75,000 - $100,000 $100,000 - $150,000 Over $150,000 8. Any additional comments or explanations?
