Name
*
First Name
Last Name
Email
*
Birth date
*
MM
DD
YYYY
Gender identity
*
Woman
Man
Transgender
Non-binary/non-conforming
Prefer not to respond
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone (primary)
*
Country
(###)
###
####
Phone (secondary)
Country
(###)
###
####
Marital status
*
Never married or single
Married
Divorced or separated
Widowed
Highest level of education
*
High school graduate
Some college
Associates and/or bachelor's degree
Masters degree
Doctoral or professional degree
Annual household income
*
Under $15,000
$15,001-$24,999
$25,000-$34,999
$35,000-$49,999
$50,000-$74,999
$75,000-$99,999
$100,000-$199,999
$200,000 and over
Employment status
*
Unemployed
Part-time employed
Full-time employed
Self-employed
Job title
*
Industry
*
Agriculture, forestry, fishing and hunting
Mining
Utilities
Construction
Computer and electronics manufacturing
Other manufacturing
Wholesale
Retail
Transportation and warehousing
Publishing
Software
Telecommunications
Broadcasting
Information services and data processing
Finance and insurance
Real estate, rental and leasing
College, university, and adult education
Primary/secondary (K-12) education
Other education industry
Healthcare and social assistance
Arts, entertainment, and recreation
Hospitality (hotel and food service)
Government and public administration
Legal services
Scientific or technical services
Homemaker
Military
Religious
Other
How many people reside in your household (including yourself)?
*
Family member 2 name
First Name
Last Name
Family member 2 birth date
MM
DD
YYYY
Family member 2 gender identity
Woman
Man
Transgender
Non-binary/non-conforming
Prefer not to respond
Family member 3 name
First Name
Last Name
Family member 3 birth date
MM
DD
YYYY
Family member 3 gender identity
Woman
Man
Transgender
Non-binary/non-confirming
Prefer not to respond
Family member 4 name
First Name
Last Name
Family member 4 birth date
MM
DD
YYYY
Family member 4 gender identity
Woman
Man
Transgender
Non-binary/non-conforming
Prefer not to respond
Family member 5 name
First Name
Last Name
Family member 5 birth date
MM
DD
YYYY
Family member 5 gender identity
Woman
Man
Transgender
Non-binary/non-conforming
Prefer not to respond