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Screening Form

Please tell us a little bit about yourself by answering the following questions.

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* 1. Your first name

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* 2. Your last name

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* 3. Preferred method of contact?

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* 4. Your email address

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* 5. Your phone number (optional)

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* 8. What is your gender?

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* 9. Which of the following racial/ethnic group do you identify with?

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* 10. Are you legally blind?

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* 12. Which of the following best describes your current employment status?

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* 13. Have you ever received disability benefits?

0 of 13 answered
 

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