Questionnaire for Discussion Groups

Question Title

1. Please provide some basic information about yourself. (Required.)

Name: *

ZIP: *

Email Address:

Phone Number: *

Question Title

2. Are you male or female? (Required.)

Male

Female

Question Title

3. What is your age? (Required.)

Under 16

16 to 29

30 to 44

45 to 59

60 and above

Question Title

4. Which of the following best describes your racial or ethnic group? (Required.)

African-American

Asian

Caucasian, European, or white

Hispanic or Latino

Other

Other (please specify)