First Name
Last Name
Phone
Email
Age
Age: = 56+
Age: = 46-55
Age: = 36-45
Age: = 26-35
Age: = 18-25
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Gender
Male
Female
Non Binary
Other
Prefer Not to Say
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Race
Asian
Black or African American
Native Alaskan
Native American Indian
Native Hawaiian/Pacific Islander
White or Caucasian
Other
Prefer to Not Say
Ethnicity
Hispanic/Latino Origin
Non Hispanic/Latino Origin
Prefer to Not Say
Marital Status
Single: Never Married
Single: Divorced
Married
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Household Status: Head of Household
Head of Household
Not Head of Household
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Household: # Persons < 18 Years Living in House
Household: # Persons > 18 Years Living in House
Household: Income (ALL - Combined)
Wealthy: > $350,000
High Income: = $100,000 - $349,999
Middle Income: = $50,000 - $99,999
Low Income: = $30,000 - $49,999
Very Low Income: = $15,000 - $29,999
Extremely Low Income: < $14,999
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Household: Income (YOU - Only)
Wealthy: > $350,000
High Income: = $100,000 - $349,999
Middle Income: = $50,000 - $99,999
Low Income: = $30,000- $49,999
Very Low Income: = $15,000 - $29,999
Extremely Low Income: = < $14,999
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Educational Attainment
Completed: Doctorate Degree
Completed: Graduate Degree
Completed: Bachelor Degree
Completed: Associate Degree
Completed: Some College (No Degree)
Completed: High School/GED/HSED
Did Not Complete: High School/GED/HSED
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Employment Status
Retired
Employed: = 40 Hours per Week +
Employed: < 40 Hours per Week
Not Employed
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Military/Veteran Status
Active Duty
Veteran
Non Veteran
Other
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Disability Status
I identify as a person with a Disability.
I do NOT identify as a person with a Disability.
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Religious Participation
Attends Church Always (Weekly)
Attends Church Sometimes (Monthly)
Attends Church Periodically (Few Times Per Year)
Has Not Attended Church in the Past Year
Has Not Attended Church in the Past 5 Years+
Does Not Attend Church
Prefer Not to Say
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Housing Type
Own
Rent
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Community Type
Urban (City)
Suburban
Rural (Country)
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Physical Health Status
Self Reports Excellent Physical Health
Self Reports Good Physical Health
Self Reports Poor Physical Health
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Mental Health Status
Self Reports Excellent Mental Health
Self Reports Good Mental Health
Self Reports Poor Mental Health
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Community Involvement
Volunteer Consistently
Volunteer Occasionally
Has Not Volunteered in the Past Year
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