Mail Study #1216

Question Title

* 1. Contact Information

First Name

Last Name

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

Question Title

* 2. Gender:

Male

Female

Transgender

Non-binary

Genderqueer or gender nonconforming

Other (please specify)

Question Title

* 3. Which of the following best describes your race or ethnic heritage?

African American

Asian

Caucasian

Hispanic/Latino

Native American

Other (please specify)