1.

1. Please complete the contact information below.

2. What is your gender?

3. Which of the following age categories best describes your age?

4. Do you have any of the following conditions?

5. Do you currently take a prescription medication for daily use?

6. What type of health insurance, if any, [are you/is your child] covered by?

7. Are you, or is an immediate family member, currently or within the past 6 months employed by or under contract with any of the following?

8. Approximately which best describes your highest attained education level?

9. What is your ethnicity?

10. Into which of the following bands does your annual household income fall?

11. What is your current work status?

12. What is your Occupation-Job Title, Company you work for, and Industry?

(If you are Retired, Unemployed or a Homemaker Please tell us your previous employment information. If you are a full-time student please enter your Grade, School and Major)

13. 9. What is your current marital status?

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