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9 Month Employment Survey
Identification Information
*
1
. First and Last Names
First and Last Names
2
. Address
Address
3
. Phone Number
Phone Number
*
4
. Email Address
Email Address
5
. Birthdate
Birthdate
6
. Gender
Gender
Male
Female
7
. Race/Ethnicity (you may check up to 2 answers)
Race/Ethnicity (you may check up to 2 answers)
Hispanic/Latino
Black or African-American (includes Caribbean)
Asian-American/ Pacific Islander (describe)
East Indian/Pakistani
American Indian/ Native American (describe)
White/Caucasian
Description (if requested above)
8
. Disability
Disability
Not Disabled
Visual Impairment
Hearing Impairment
Mobility Impairment
Other (please specify)
Specify if you answered "other"
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