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1
. What is your name?
What is your name?
2
. What is the best phone number for us to contact you on?
What is the best phone number for us to contact you on?
3
. What is your gender?
What is your gender?
Male
Female
4
. What is your age?
What is your age?
5
. Which of the following best describes your domestic status?
Which of the following best describes your domestic status?
Married/Living with partner
Single
6
. Do you have any children under 18 living at home with you?
Do you have any children under 18 living at home with you?
Yes
No
7
. What was the last grade of school you completed?
What was the last grade of school you completed?
Some high school or less
High school graduate
Some college
College graduate
Graduate school
8
. What is your current employment status?
What is your current employment status?
Employed Full-Time
Employed Part-Time
Full-Time student
Homemaker
Retired
Unemployed
9
. Which of the following best describes you total annual household income before taxes?
Which of the following best describes you total annual household income before taxes?
Under $25K
$25K to $29K
$30K to $39K
$40K to $49K
$50K to $74K
$75K to $99k
$100k or more
10
. What industry, if any, do you currently work in (if not employed please type NONE below)?
What industry, if any, do you currently work in (if not employed please type NONE below)?
11
. What is your ethnicity?
What is your ethnicity?
African American
Asian
Caucasian
Hispanic
Other
12
. What state/city do you currently reside in?
What state/city do you currently reside in?
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