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First Name
Last Name
Email
Cell Phone
Address (street)
City
State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code
Do you give EurekaFacts permission to text you about research studies? YesNo
What year were you born? 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930
Please describe your gender. Male Female Non-Binary Prefer not to answer Not listed/Prefer to self-identify
Are you of Hispanic/Latino origin? YesNo
What's your race/ethnicity? (Please select all the answers that apply to you). White/CaucasianHispanic/LatinoBlack or African AmericanAsian/Pacific IslanderAmerican Indian/Alaskan NativeMiddle Eastern/North AfricanPrefer not to answerNot listed
What is the highest level of education you have completed? (Please select one) Less than High School Diploma GED or High School Graduate (Diploma) Some Higher Education College Graduate Master's Degree Doctoral Degree
What is your annual household income? $0-$15,000 $15,001 - $25,000 $25001 - $50,000 $50,001 - $75,000 $75,001 - $100,000 $150,001 or more
How many people live in your household? 1 2 3 4 5 6 7 8 9 10 11
What is your marital status? Single never married Single separated of divorced Single widowed Now married Prefer not to answer
Tell us who else lives in your household (select all that apply) Children 0 - 5 (born between 2017 and 2023) Children 6 - 13 Children 14 - 18 Adults 19 - 24 Adults 25 - 64 Adults 65 years and older
Which of the following best describes your job category? Government Management Self-employed Skilled worker Manual worker Administrative Retail Public sector worker Healthcare Education (Teacher) Education (Other/Non-Teacher) Agricultural Professional Military Other
Job Title
Have you ever served on active duty in the U.S. Armed Forces, military Reserves, or National Guard?” YesNo
What languages do you speak at home? (Select all that apply) Amharic Arabic Chinese (any) English French German Japanese Korean Other Portuguese Russian Spanish Vietnamese
Do you use any of these social media channels? (Select all that apply) None Facebook Instagram Twitter WhatsApp TikTok Snapchat YouTube Telegram Line WeChat VK Wattpad Tumblr Reddit Pinterest LinkedIn Sina Weibo Youku Snow Qzone Other
How do you prefer to receive communications? Face-to-face communication (for instance, video conferencing or in person) Phone calls Text messages Instant messaging/live chat Emails Social media Radio Television Newspaper Other printed
Would you like to provide more information on your profile to be considered for our healthcare panel? Yes No
Is there anyone in your household with any of the following health care coverage? Health Insurance Prepaid plans Tricare (coverage for the military and their families) Medicare Indian Health Service coverage No coverage Prefer not to answer (Please select all that apply.)
Do you or any members of your household have a disability? None Visual impairments Hearing impairments Motor impairments Cognitive impairments (Please select all that apply.)
As far as you know, have any members of your household including yourself been diagnosed with a chronic medical or mental health condition? None Arthritis Asthma Cancer Chronic obstructive pulmonary disease Diabetes Heart Disease High Blood Pressure/Stroke Obesity (Select all that apply.)
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