Fritz: All Fritz/All Fritz.zip/All Fritz/FILES/MISCEOUS/HEART.LZH/5.DAT

Text File | 1987-09-07 | 6KB | 392 lines

                    Background Information Questions


Ethnic  Background
        1.  Afro-American (Black)
        2.  Caucasian (White)
        3.  Hispanic
        4.  Asian-American
        5.  American Indian
        6.  Other


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Your religious affiliation
        1. Baptist
        2. Catholic
        3. Lutheran
        4. Methodist
        5. Jewish
        6. Other Protestant
        7. Atheist or Agnostic
        8. Other


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What is your individual yearly income (not your household income)?

        1.  No Income
        2.  under $5000
        3.  $5000 to $10,000
        4.  $11,000 to $15,000
        5.  $16,000 to $20,000
        6.  $21,000 to $30,000
        7.  $31,000 to $40,000
        8.  $41,000 to $70,000
        9.  $71,000 to $100,000
        10. over $100,000


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Highest level of education completed:
        1.  Elementary School
        2.  Some High School
        3.  Finished High School
        4.  Some College or Technical School
        5.  Finished Four Year College Program
        6.  M.A.
        7.  Ph.D.


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What is your occupation (pick the closest answer)?
        1.  Professional: Doctor, Lawyer, Scientist, Top Level Manager
        2.  Creative: Performer, Photographer, Writer, Advertising
        3.  Entrepreneur: Business Owner, Investor
        4.  Other professional: Middle Manager, Teacher, Social Worker
        5.  Sales
        6.  Skilled Trades: Construction, Farmer
        7.  Office Worker: Clerical, Secretary
        8.  Unskilled Trade: Laborer, Factory, Waiter/Waitress
        9.  Homemaker
        10. Student


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What is your job status?
        1. Full Time
        2. Part Time
        3. Freelance
        4. Unemployed


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Where do you live?
        1. Farm
        2. Rural but not farm
        3. Town, 2500 or less
        4. Town, 2500 to 25,000
        5. Small City 25,000 to 100,000
        6. Inner City Area of Large City, over 100,000
        7. Suburban Area of Large City,  over 100,000


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What are you current living arrangements?
        1.  With my parents
        2.  Alone
        3.  With roommate(s)
        4.  With the person with whom I am doing this questionnaire
        5.  With a partner other than the person with whom I am doing this
            questionnaire


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What is your parents' marital status?
        1. Married: living together
        2. Married: separated
        3. Divorced and single, both
        4. Divorced and remarried, both
        5. Divorced, one single, one remarried
        6. Single (partner deceased)
        7. Remarried (partner deceased)
        8. Both deceased


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How would you characterize your parent's marriage on a scale of 1 to 10 where
1 = Least Succesful and 10 = Most Succesful?

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Have you had sexual intercourse with your partner?    Yes   No


Is the woman pregnant?                                Yes   No


Have you had any children with your current partner?  Yes   No


                                          How many ?  0  1  2  3  4  5  more

Have you ever been married to someone other than your
current partner?                                      Yes   No


Do you have any children from a previous marriage?    Yes   No


        Are any of them currently living with you?    Yes   No








How many months have you known your current partner?  Enter months:

If you are not married and plan to marry,
in how many months do you plan to marry?              Enter months:

Your age in years?                                    Enter years:

Please enter the approximate time in minutes that
it took you to complete the Heart To Heart
Questionnaire.                                        Enter minutes:









                     User Evaluation of the Questionnaire



How honest were you in answering the questions on a scale of 1 to 10 with 1
being "least honest" and 10 being "100% honest"?

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How useful has this program been to you and your partner with 1 being
"Least Useful" and 10 being "Most Useful"?



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Is the questionnaire:

         1. Too short?
         2. About the right length?
         3. Too long?


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What is your overall feeling about your experience with the questionnaire
where 1 = "most negative" and 10 = "most positive"

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Would you recommend the questionnaire to your friends?

            1. Yes, without reservations
            2. Yes, except for a few cases
            3. Yes, but only for a few of them
            4. Not sure at present
            5. No
            6. I would stongly advise them against using it


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What did we leave out of the questionnaire?
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Do you have any other comments, suggestions, or feedback?
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