Pact, An Adoption Alliance - Project Building Understanding Demographic Information

Building Understanding Project Demographic Information

It's important that you know that your confidentiality will be maintained at all times. We will not share the information you provide us with anyone else and no one will know about your participation (unless you tell them). Participating is entirely voluntary. You can decline to answer any questions or you can stop being part of the study at any time you choose. If there is anything else you would like to share about your family's background, please use additional paper to do so. If this is a two parent family, we ask that this form and the questionnaire we will mail you later be completed by the same person, who must also be one of the parent(s) who originally adopted the children listed.
Optional: want to know more about the kind of families we are investigating?
Click here.

Interested in participating in a special follow-up of the Building Understanding study called the "Adoptive and Birth Families Study?" Click here.

Name:

Street Address:

City, State, Zip:

Telephone (home):

Telephone (work - optional):

Email Address:

1. What is your role in the family? Adoptive Mother Adoptive Father

2. Please tell us who currently lives in your home and what your relationship is to them.
Please include their names and their relationship to you.

3. What is your date of birth?

4. What is your current marital/partner status? Never married Married, living with spouse

Married but separated Living with partner, unmarried

Single - divorced Single - Widowed

Other:

5. What was your marital/partner status at the time of the adoption? Never married Married, living with spouse

Married but separated Living with partner, unmarried

Single - divorced Single - Widowed

Other:

6. If you currently have a spouse/partner, what is your current spouse/partner's date of birth?

7. What would most closely describe your household? Heterosexual Gay/Lesbian

8. What is the highest level of education you have completed? Grade school High school or GED

Vocational school Junior/community college or received A.A

Four-year college Graduate school

9. What is the highest level of education your current spouse/partner has completed? Grade school High school or GED

Vocational school Junior/community college or received A.A

Four-year college Graduate school

10. Please indicate the racial or ethnic background of you, your parents, your current spouse/partner, and his/her parents' racial or ethnic background. (CHECK ALL THAT APPLY)

Asian or
Pacific Islander Black or
African American Hispanic
or Latino Native
American
or
American
Indian White or
Caucasian Other

You

Your mother

Your father

Spouse/partner

Spouse/partner's mother

Spouse/partner's father

11. With which racial/ethnic groups do you and your current spouse/partner most identify or relate to? (This may be different than your primary racial/ethnic background) (CHECK ALL THAT APPLY)

Asian or
Pacific Islander Black or
African American Hispanic
or Latino Native
American
or
American
Indian White or
Caucasian Other

You

Your partner

12. For the year 2001, what was your approximate gross (before taxes) household income? Less than $20,000 $80,000 - $99,999

$20,000 - $39,999 $100,000 - $149,999

$40,000 - $59,999 $150,000 - $199,999

$60,000 - $79,999 $200,000 or more

13. How important is the role of religion or spirituality in your family in general? Not at all important

Somewhat important

Very important

14. What religion does your family practice? None Jewish

Christian Muslim

Buddhist Hindu

Other

15. What other adoption triad roles apply to you or your spouse/partner? CHECK ALL THAT APPLY.

You Spouse/Partner

Birth Parent Who Placed Child for Adoption

Adopted Person

16. Which designation most closely describes the community where your family currently resides?

Urban (approximate population of 50,000 people or more)

Large town (approximate population of 10,000 - 50,000 people)

Small town (approximate population of 2,500 - 10,000 people)

Rural or farm (approximate population of less than 2,500 people)

17. To what extent are the following groups found in the neighborhood in which your family currently resides?

Not at all A few Large numbers The largest group

Asian or Pacific Islander

Black or African American

Hispanic or Latino

Native American or American Indian

White or Caucasian

Biracial or multiracial

Other

If "other", please specify:

18. Below, please write in the first name of each child in your family WHO WAS BORN TO YOU OR YOUR PARTNER. For each child, indicate the child's gender, date of birth and race(s) or ethnicity(ies) Please check only one category for race/ethnicity.

NONE (go directly to the next question)

Please note: this table is wide and may require scrolling to the right to complete.

Full name Gender Date of birth Asian/
Pacific
Islander Black/
African
American Hispanic/
Latino Native
American/
American
Indian White/
Caucasian Mixed
at least
half
Black Other
please specify

M  F

M  F

M  F

M  F

M  F

M  F

M  F

M  F

M  F

M  F

M  F

M  F

19. Below, please write in the first name of each child in your family WHO JOINED THE FAMILY THROUGH ADOPTION in the order in which they arrived. For each child, indicate the child's gender, date of birth, race(s) or ethnicity(ies), the date the child entered your family (month & year), the date the child's adoption was finalized (month & year) and the method of adoption. Please note: if your child's adoption has not yet finalized please write "pending" in the space provided for the date of finalization.

Please note: this table is wide and will require scrolling to the right to complete.

Please place an asterisk * next to the name of each adopted child who is biologically related to you or your partner.

Method of Adoption

Full name Gender Date of birth Asian/
Pacific
Islander Black/
African
American Hispanic/
Latino Native
American/
American
Indian White/
Caucasian Mixed
at least
half
Black Other
specify Arrival date
into your
family
(month/year) Finalization
date
(month/year) Public Agency Foster Adopt/ Public Agency Private Agency (Domestic) Independent (no agency) International

M  F

M  F

M  F

M  F

M  F

M  F

M  F

M  F

M  F

M  F

M  F

M  F

M  F

Name:
Street Address:
City, State, Zip:
Telephone (home):
Telephone (work - optional):
Email Address:

1. What is your role in the family?	Adoptive Mother Adoptive Father

4. What is your current marital/partner status?	Never married	Married, living with spouse
	Married but separated	Living with partner, unmarried
	Single - divorced	Single - Widowed
	Other:

5. What was your marital/partner status at the time of the adoption?	Never married	Married, living with spouse
	Married but separated	Living with partner, unmarried
	Single - divorced	Single - Widowed
	Other:

6. If you currently have a spouse/partner, what is your current spouse/partner's date of birth?

7. What would most closely describe your household?	Heterosexual	Gay/Lesbian

8. What is the highest level of education you have completed?	Grade school	High school or GED
	Vocational school	Junior/community college or received A.A
	Four-year college	Graduate school

9. What is the highest level of education your current spouse/partner has completed?	Grade school	High school or GED
	Vocational school	Junior/community college or received A.A
	Four-year college	Graduate school

	Asian or Pacific Islander	Black or African American	Hispanic or Latino	Native American or American Indian	White or Caucasian	Other
You
Your mother
Your father
Spouse/partner
Spouse/partner's mother
Spouse/partner's father

12. For the year 2001, what was your approximate gross (before taxes) household income?	Less than $20,000	$80,000 - $99,999
	$20,000 - $39,999	$100,000 - $149,999
	$40,000 - $59,999	$150,000 - $199,999
	$60,000 - $79,999	$200,000 or more


13. How important is the role of religion or spirituality in your family in general?	Not at all important
	Somewhat important
	Very important


14. What religion does your family practice?	None	Jewish
	Christian	Muslim
	Buddhist	Hindu
	Other

	You	Spouse/Partner
Birth Parent Who Placed Child for Adoption
Adopted Person

	Not at all	A few	Large numbers	The largest group
Asian or Pacific Islander
Black or African American
Hispanic or Latino
Native American or American Indian
White or Caucasian
Biracial or multiracial
Other
If "other", please specify:

Full name	Gender	Date of birth	Asian/ Pacific Islander	Black/ African American	Hispanic/ Latino	Native American/ American Indian	White/ Caucasian	Mixed at least half Black	Other please specify
	M F
	M F
	M F
	M F
	M F
	M F
	M F
	M F
	M F
	M F
	M F
	M F