*1.Contact Info(Required.)

Name

Phone

E-Mail

*2.Are you...(Required.)

Male

Female

Prefer to self-identify:

*3.Please state your age(Required.)

*4.In which state is your primary residence?(Required.)

*5.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 – other Hispanic, Latino, or Spanish origin

*6.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. Asian

5. Native Hawaiian or other Pacific Islander

Other (please specify)

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

1. Working full time (30 or more hours per week)

2. Working part time (Less than 30 hours per week)

3. Full time student

4. Retired

5. Unemployed

6. Other not working

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

Occupation

Industry

Employer