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Name
*
First
Last
Email
*
What is your gender?
*
Gender
Male
Female
Other
Which category below includes your age?
*
Age
18-20
21-29
30-39
40-49
50-59
60 or older
What’s your ethnicity?
*
White
Black or African-American
American Indian or Alaskan Native
Asian
Native Hawaiian or Other Pacific islander
Hispanic or Latino
Other
Are you now married, widowed, divorced, separated, or never married?
*
Status
Married
Widowed
Divorced
Separated
Never married
What is the highest level of school you have completed or the highest degree you have received?
*
Education
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?
*
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
Disabled, not able to work
How much total combined money did all members of your household earn last year?
*
Household Income
$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 – $69,999
$70,000 – $79,999
$80,000 – $89,999
$90,000 – $99,999
$100,000 or more
Which of the following best describes your current occupation?
*
Choose Occupation
Agriculture, Food and Natural Resources
Architecture and Construction
Education and Training
Business Management and Administration
Arts, Audio/Video Technology and Communications
Finance
Government and Public Administration
Health Science
Hospitality and Tourism
Human Services
Information Technology
Law, Public Safety, Corrections and Security
Manufacturing
Market Research
Marketing, Sales and Service
Science, Technology, Engineering and Mathematics
Transportation, Distribution and Logistics
Country
*
USA
Canada
Other
Provinces and territories
Choose Provinces and Territories
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
State
Choose State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky[D]
Louisiana
Maine
Maryland
Massachusetts[D]
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania[D]
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia[D]
Washington
West Virginia
Wisconsin
Wyoming
District of Columbia
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