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Research Participant Sign-Up



Thanks for your interest in participating in our research studies.

In order to be considered for research participation, please fill out this screener questionnaire. COMPLETION OF THIS
QUESTIONNAIRE IS NOT COMPENSATED but we do need to hear from you before we can consider you for participation in a research study.

Our research studies are important research efforts so we appreciate your providing us with complete and accurate information.
The information you provide will be kept confidential and is only used to invite you to participate in the research studies for
which you may be an eligible participant. We do not sell or rent our lists and do not use them to sell products or services.


This questionnaire is intended for adults as well as minors over 13 years of age. IF YOU ARE YOUNGER THAN 18, YOU WILL NEED
TO PROVIDE CONTACT INFORMATION FOR YOUR PARENT/GUARDIAN IN ORDER TO PARTICIPATE IN ANY RESEARCH
ACTIVITIES.

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Please provide us with the following information.
First name
Last name
Best phone number to reach you
Email address
Re-type email address



In which state do you primarily reside?



What is your zip code? (If you currently reside in the U.S.)
Zip code



In what year were you born?



IF YOU ARE UNDER AGE 18, YOU MUST PROVIDE CONTACT INFORMATION FOR YOUR PARENT/GUARDIAN.
First name of parent/guardian
Last name of parent/guardian
Best phone number to reach parent/guradian
Email address of parent/guardian
Re-type email address of parent/guardian



What is your gender?
Male Female




What do you consider to be your racial or ethnic background?  (Please select all that apply)


White/Caucasian
Hispanic/Latino
Black or African American
Asian/Pacific Islander
American Indian or Alaskan Native
Other  



What is the highest level of education you have completed?





What is your annual household income?





Which of the following best describes your current employment status?





Which of the following best describes your job category?

Government
Management
Self-employed
Skilled worker
Manual worker
Administrative
Retail
Public sector worker
Healthcare
Education
Agricultural
Professional
Military
Other