Potential Respondent form

Personal Information

Gender Male Female

D.O.B.

Contact Information

Address

City

State

Zip

Email Address

Cell Phone

No land-line home number, I only use cell.

Home Phone

Work Phone

Miscellaneous Information

Employment Employed full-timeEmployed part-timeSeeking employmentFull-time homemakerStudent orRetiredDISABLED

Occupation Executive or ownerProfessional or specialtyManagement or administratorTechnical and related supportSalesClerical and administrative supportService occupations orOr something else?
'Or something else?' includes farming, forestry, fishing, precision production, crafts and repair work, machine operators, inspectors and administrators, transportation and material movers, handlers equipment cleaners, helpers and laborers

Total Household Income Under $20,000$20 to 40,000$40 to 60,000$60 to 80,000$80 to 100,000$100,000 to $150,000Over $150,000REFUSED

Education Less than a high school diplomaHigh schoolSome collegeCollege degreeAdvanced degreeOccupational/TechnicalREFUSED