*1.Contact Info(Required.)

Name

Phone

E-Mail

Gender

Age

State

*2.What is your annual household income (before tax)?(Required.)

1. My household does not have an income

2. Under $15,000

3. $15,000 to $24,999

4. $25,000 to $34,999

5. $35,000 to $49,999

6. $50,000 to $74,999

7. $75,000 to $99,999

8. $100,000 to $149,999

9. $150,000 to $199,999

10. $200,000 and over

*3.Are you of Hispanic, Latino, or Spanish origin?(Required.)

1. No

2. Yes – Mexican, Mexican American, Chicano

3. Yes – Puerto Rican

4. Yes – Cuban

5. Yes – Brazilian

6. Yes – other Hispanic, Latino, or Spanish origin

*4.Which of these best describes your racial background?

Please select all that apply.(Required.)

1. White

2. Black or African American

3. American Indian or Alaskan Native

4. East Asian

5. South Asian

6. Native Hawaiian or other Pacific Islander

7. Middle Eastern

Other (please specify)

*5.Which of the following languages do you speak fluently and/or at home?

Please select all that apply.(Required.)

Spanish

Chinese (Mandarin)

Arabic

English

French

Portuguese

German

Russian

Korean

Japanese

Italian

Other (please specify)

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

Less than a high school diploma

High school degree or equivalent (e.g., GED)

Some college, no degree

Associate’s degree

Trade certification or technical degree

Bachelor's degree

Master’s degree

Professional degree

Doctoral degree

*7.What is your current employment status?(Required.)

Working full time (40 or more hours per week)

Working part time (less than 40 hours per week)

Full time student

Retired

Unemployed

Other (not working)