Demographics

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* 1. What is your first name?

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* 2. What is your last name?

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* 3. What is your date of birth?

Date

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* 4. What is your street address?

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* 5. In what city do you live?

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* 6. In what ZIP code is your home located? (enter 5-digit ZIP code; for example, 00544 or 94305)

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* 7. Do you live in Kentucky?

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* 8. What Kentucky county do you live in?

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* 9. What is your home telephone number?

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* 10. What is your cell phone number?

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* 11. What is your email address?

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

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* 13. Which of the following best describes your current relationship status?

T