Psychology

Florida International University – [Insert FIU Lab Here]

Demographic Information Survey

ID: ________________________ Date of Study: _______________________

Child’s Birth date: __________________ Child’s Gender: Female _______ Male ________

Ethnic Category (choose one):

_________ Hispanic or Latino _________ Not Hispanic or Latino

Racial Category (choose one):

_________ Native American/Alaska Native _________ Black or African American

_________ Asian _________ White

_________ Native Hawaiian or Other Pacific Islander _________ Other (please specify):________________________

Parent’s education: Mother: Father:

____ High School Graduate ____ High School Graduate

____ Associates Graduate ____ Associates Graduate

____ College Graduate ____ College Graduate

____ Graduate School Graduate ____ Graduate School Graduate

____ Other​​​​​​_________________ ____ Other_________________

Parent employment: Mother: ________ hrs/wk (typical hours after maternity leave)

Father: ________ hrs/wk

Child Handedness:

_________ Left _________ Right

Has your child ever experienced any traumatic brain injuries or insults?

_________ No _________ Yes (approx. date): ____________________________

Has your child ever been diagnosed with a neurological disorder?

_________ No _________ Yes (please specify):___________________________

Has your child ever been diagnosed with a psychological disorder?

_________ No _________ Yes (please specify):___________________________

Has your child ever been diagnosed with a learning disability?

_________ No _________ Yes (please specify):___________________________

If yes, does your child currently have a diagnosis?

_________ No _________ Yes

Is your child taking any medications for their disorder?

_________ No _________ Yes (please specify): __________________________