All of your answers will remain confidential and will only be used for matching your profile to the needs of a study. We do not share information with anyone.
All required information in Bold Red
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Contact Information |
| How did you learn about this panel? |
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| - Please Specify |
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| First Name |
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| Last Name
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| Day Phone |
1 (
)
-
ext
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| Evening Phone |
1 (
)
-
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| Cell Phone |
1 (
)
-
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| E-mail: (There will be specific studies to be completed over the internet. We will not be contacting you by e-mail except to invite you to a study or to make sure the e-mail address is still active.) |
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| What is your computer connection speed? |
Dial-Up:
Broadband (DSL, Cable, T1):
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| Street Address: |
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| City: |
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| State: |
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| Zip code: |
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| What is the best day to reach you? |
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| May we contact you during the weekend? |
Yes: No: |
| What is the best time of day to reach you? |
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| May we leave a message on your voicemail or answering machine? |
Yes: No: |
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Personal Information |
| Gender: |
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| Birth date: |
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| Age: |
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| What is the highest grade or level of education you have completed? |
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| - if other please specify |
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| Are you working... |
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| If yes, what is your occupation? |
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| What is your annual household income? |
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| Which of the following categories best represents your race? |
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| - if other please specify |
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| What is your religious affiliation? |
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| - if other please specify |
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| What is your sexual orientation? |
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| - if other please specify |
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| What is your current relationship or marital status |
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