Contact Tracing Registration Form Question Title * 1. First Name Question Title * 2. Last Name Question Title * 3. Date of Birth (mm/dd/yy) Question Title * 4. Email Address Question Title * 5. Phone Number Question Title * 6. What is the address where you currently live? Question Title * 7. Are you an ASU undergrad student pursuing this opportunity for academic credit Yes, I am enrolled in a capstone class Yes, as an internship for spring semester No, I am volunteering and/or a student at another school Question Title * 8. Gender Male Female Prefer not to say Other Question Title * 9. Ethnicity Hispanic/Latinx/Latino Non-Hispanic Question Title * 10. Race Black or African American American Indian/Alaska Native Asian Hawaiian/Pacific islander White/Caucasian More than one race Other (please specify) Question Title * 11. Did you spend the majority of your life before age 18 in a rural area? (population <50,000)? Yes No I don't know Question Title * 12. Do you consider yourself disadvantaged?Meets the following criteria: 1. Comes from an environment that has inhibited them from obtaining the knowledge, skills, and abilities required to enroll in and graduate from a health professions or nursing school (Environmentally Disadvantaged); AND/OR 2. Comes from a family with an annual income below a level based on low-income thresholds established by the U.S. Census Bureau, adjusted annually for changes in the Consumer Price Index (Economically Disadvantaged). Yes No I don't know Question Title * 13. Do you speak Spanish? Yes No Question Title * 14. What college or university are you currently attending? Question Title * 15. What is your current program of study or major? Question Title * 16. What year did you start your current academic program? Question Title * 17. What is your anticipated graduation date? Question Title * 18. Enrollment Status: Full-time Part-time Inactive Leave of absence Done
