Thank you for your interest in participating in research studies. Please answer the following questions to the best of your ability. If you may be qualified for a study, we will contact you directly with more information.

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1. Have you or anyone in your immediate household ever worked in any of the following industries? Please select all that apply. (Required.)

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2. Where do you currently live? (Required.)

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3. Which category best describes your age? (Required.)

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4. What is your gender? (Required.)

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5. What is your race or ethnicity? (Required.)

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6. What is the highest level of education you have completed? (Required.)

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7. What is your approximate total annual household income? (Required.)

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8. What is your current employment status? (Required.)

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9. In what industry are you currently employed? (Required.)

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10. Which of the following best describes your household? (Required.)

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11. What is your name? (Required.)

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13. What is the best phone number to reach you? (Required.)

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