Name: Organizational Session at Memorial CDC
Start: 2021-01-18T03:00:00-06:00
End: 2021-01-18T17:00:00-06:00

Your Demographics

This information is anonymous but is vitally important in making sure we are reaching ALL people in the region! Help us by providing the following info:

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Organization(s)

If you are part of multiple organizations, please indicate each and separate them with commas.

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What is your marital status?

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What is your age?

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County of Residence

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Have you or anyone in your household served on active duty in the U.S. Armed Forces, Reserves, or National Guard?

Your Zip code:

What is your age?

Please enter a number less than or equal to 120.

What gender were you assigned at birth?

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Do you or anyone in your household identify as LGBTQA+?

What is your current gender?

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5. Which of the following describes your race?

Which of the following describes your race?

American Indian or Alaskan Native
Asian
Black or African American
Hawaiian or Other Pacific Islander
Two or More Races
White
Other

Please specify "other" race

Are you of Hispanic or Latino/a/x origin?

Yes
No
Prefer not to answer

Do you or someone in your household identify as LGBTQIA+?

Yes, me
Yes, someone in my household
No
Prefer not to answer

Have you or anyone in your household served on active duty in the U.S. Armed Forces, Reserves, or National Guard?

Yes, me
Yes, someone in my household
No
Prefer not to answer

Do you or someone in your household have a physical or cognitive disability, either visible or not? (Please check any that apply)

Yes, I have a disability
Yes, someone in my household has a disability
No
Prefer not to answer

What is your marital status?

Cohabitating couple household
Divorced
Legal domestic partnership/civil union
Married
Never married
Separated
Single
Widowed
Other

Choose all that apply.

Please specify "other" marital status

What is the highest degree or level of school you've completed?

Please specify "other" schooling

Which best describes the sector in which you are currently or were most recently employed?

Please specify "other" employment

What is your total estimated household income?

Including yourself, how many people live in your household?

Please enter a number from 0 to 100.

Do you own or rent your residence?

Please specify "other" residence

How would the area you live in be described?

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Do you have access to the internet in your household?

Which type of computer do you have access to in your home?

Desktop or laptop
No computer
Smartphone
Tablet or other portable wireless computer
Other

Please specify "other" computer

What kind of internet access do you have at your home?

Broadband (ie Cable, Fiber Optic,DSL)
Cellular data plan with no other type of Intenet subscription
Dial-up
No internet subscription
Satellite
Other

Please specify "other" internet

What form of transportation do you normally use?

Bicycle/Scooter
Motorcycle
Personal vehicle
Public Transportation/Bus
Rely on relatives/friends
Taxi, Uber, Lyft, etc.
Walk
Prefer not to answer
Other

Please specify "other" transportation

What is your present religion?

Please specify "other" religion

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Describe your current housing:

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Including yourself, how many people live in your household?

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Your Neighborhood

What neighborhood to do you live in? Leave blank if you don't know.

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What is the highest degree or level of school COMPLETED?

Organizational Session at Memorial CDC

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