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* 1. I am:

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* 2. I am:

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* 3. My age Is:

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* 4. If married/committed relationship my spouse's/partner's age is:

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* 5. Which ethnic background do you identify with?

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* 6. How many people live in your household including yourself? 

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* 7. My monthly household income is:

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* 8. I live:

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* 9. I live in the following KS County:

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* 10. I have access to the Internet:

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* 11. If Yes,

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* 12. If you are someone who regularly receives care from someone else please tell us who you receive care from. Please mark all that apply.

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* 13. I feel responsible for the well being and giving of care to another person?

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* 14. If you feel responsible for the well being and giving of care to another person, please tell us who you care for:

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* 15. What is the age of the person you are caring for?

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* 16. Does the person you feel responsible for the well being and giving care to have any of the following:

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