Household Research

Question Title

* 1. Contact info:

First and last name

City/Town

State/Province

Email Address

Phone Number

Question Title

* 2. What is your gender?

Male

Female

Other (please specify)

Question Title

* 3. What is your age?

Question Title

* 4. For classification purposes, are you currently:

Employed full time

Employed part time

Homemaker

Unemployed Student

Currently unemployed

Retired

Question Title

* 5. Who else currently lives in your home?

Child(ren) under 18

Roommate(s)

Spouse/partner

Child(ren) over 18

Someone else(please specify)