One Small Step Participant Survey

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* 1. Contact Information

Name

Address

Address 2

City/Town

State

ZIP/Postal Code

Email Address

Phone Number

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* 2. Primary language spoken?

English

Spanish

Other (please specify)

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* 3. How did you hear about One Small Step?

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* 4. Preferred method of contact

Phone

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* 5. Best time to contact you? (Please specify hours, a.m or p.m.)

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* 6. Anytime that we should not contact you?

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* 7. What is your age?

18 to 24

25 to 34

35 to 44

45 to 54

55 to 64

65 to 74

75 or older

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* 8. What is your gender?

Female

Male

Non-Binary

Prefer not to answer

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* 9. What is your current religion, if any?

Christian/Protestant/Methodist/Lutheran/Baptist

Catholic

Mormon

Greek or Russian Orthodox

Jewish

Muslim

Buddhist

Hindu

Atheist or agnostic

Nothing in particular

Prefer not to answer

Other (please specify)

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* 10. Which race/ethnicity best describes you? (Please choose only one.)

American Indian or Alaskan Native

Asian / Pacific Islander

Black or African American

Hispanic/Latino

White / Caucasian

Multiple ethnicity / Other (please specify)

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* 11. Which of the following best describes your current occupation?

Life, Physical, and Social Science Occupations

Education, Training, and Library Occupations

Healthcare Field

Transportation and Materials Moving Occupations

Community and Social Service Occupations

Military/ Government

Computer and Mathematical Occupations

Building and Grounds Cleaning and Maintenance Occupations

Arts, Design, Entertainment, Sports, and Media Occupations

Sales and Related Occupations

Business and Financial Operations Occupations

Personal Care and Service Occupations

Construction and Extraction Occupations

Architecture and Engineering Occupations

Food Preparation and Serving Related Occupations

Management Occupations

Legal Occupations

Office and Administrative Support Occupations

Retired

Other (please specify)

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* 12. Do you consider yourself a ...

Strong Republican

Republican

Lean toward Republican

Independent/ No party affiliation

Lean toward Democrat

Democrat

Strong Democrat

Other

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* 13. When you consider your political thinking, which of the following best describes you?

Consistently liberal

Mostly liberal

Mixed

Mostly conservative

Consistently conservative

Other (please specify)

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* 14. Please describe your ideal partner for this conversation (in terms of political ideology, beliefs, etc.)

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* 15. What do you want to achieve by participating in a conversation with someone who holds a different political viewpoint? (please explain in no more than 3 sentences)

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* 16. Do you have any concerns about participating in a conversation with someone who holds different political views than your own? (please explain in no more than 3 sentences)

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* 17. What time of day is best for you to participate?

Morning

Afternoon

Early Evening

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* 18. Please describe youself, including any details you think a potential conversation partner should know about you. If you are chosen, this short bio will be shared with your conversation partner prior to your discussion together.