Name First Last Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email PhoneBirthdate MM slash DD slash YYYY Were you born Male of Female? Male Female Which gender do you identify as? Male Female Non-binary Do you consider yourself to be: Asexual Bisexual Gay Straight (Heterosexual) Lesbian Pansexual Queer Questioning or unsure Other Prefer not to disclose In what type of community do you live? Suburban community City or urban community Rural community What is your race? African-American or Black American Indian or Alaskan Native Asian Multiple races Native Hawaiian or other Pacific Islander Spanish, Hispanic, or Latino White Prefer not to disclose What is the highest level of school you have completed or the highest degree you have received? Less than high school degree High school degree or equivalent (e.g., GED) Some college but no degree Associate degree Bachelor degree Graduate degree Which of the following categories best describes your employment status? Employed, working 1-39 hours per week Employed, working 40 or more hours per week Not employed, looking for work Not employed, NOT looking for work Retired Not able to work How much money did YOU personally earn in the last 12 months? This includes money from jobs; net income from business, pensions; dividends; social security payments; and any other money income received by YOU. Please do not subtract the amount you paid in taxes or any deductions listed on your tax return. $0- $9,999 $10,000 - $19,999 $20,000 - 29,999 $30,000 - $39,999 $40,000 - $49,999 $50,000 - $59,999 $60,000 - $79,999 $80,000 - $99,999 $100,000 or More Δ
