*1.Contact Info(Required.)

Name

Phone

E-mail

State

Gender

Age

Year Born:

*2.Are you of Hispanic, Latino or Spanish origin? Select one(Required.)

No, not of Hispanic, Latino or Spanish origin

Yes, of Hispanic, Latino or Spanish origin

Prefer not to answer

*3.What is your race or ethnic heritage? If appropriate you may select more than one answer if this best describes you. Select all that apply.(Required.)

Black

American Indian or Alaska Native

South Asian (India, Pakistan, Bangladesh, etc.)

Southeast or East Asian (China, Japan, Korea, Philippines, Vietnam, etc.)

White/Caucasian

Prefer to self-identify (please specify ___________)

*4.Which of the following best describes your employment status?(Required.)

Employed full-time (40 hrs./wk. or more)

Employed part-time (30-40 hrs./wk.)

Employed part-time (less than 30 hrs./wk.)

Self-employed full-time or part-time

Student

Homemaker

Retired

Unemployed

Other (please specify)

*5.What is your current or previous.....(Required.)

Occupation/Title

Industry

Company You Work/Worked For