Please provide us with the following information.
Please answer question Basic Info (First name) before continuing.
Please answer question Basic Info (Last name) before continuing.
Please answer question Basic Info (Home phone) before continuing.
Your answer to question Basic Info (Home phone) must be a valid U.S. or Canadian Phone Number.
Your answer to question Basic Info (Work phone) must be a valid U.S. or Canadian Phone Number.
Please answer question Basic Info (Cell phone) before continuing.
Your answer to question Basic Info (Cell phone) must be a valid U.S. or Canadian Phone Number.
Please answer question Basic Info (Email address) before continuing.
Your answer to question Basic Info (Email address) must be a valid email address.
In which state do you primarily reside?
AK - Alaska
AL - Alabama
AR - Arkansas
AZ - Arizona
CA - California
CO - Colorado
CT - Connecticut
DC - District of Columbia (Washington)
DE - Delaware
FL - Florida
GA - Georgia
HI - Hawaii
IA - Iowa
ID - Idaho
IL - Illinois
IN - Indiana
KS - Kansas
KY - Kentucky
LA - Louisiana
MA - Massachusetts
MD - Maryland
ME - Maine
MI - Michigan
MN - Minnesota
MO - Missouri
MS - Mississippi
MT - Montana
NC - North Carolina
ND - North Dakota
NE - Nebraska
NV - Nevada
NH - New Hampshire
NJ - New Jersey
NM - New Mexico
NY - New York
OH - Ohio
OK - Oklahoma
OR - Oregon
PA - Pennsylvania
RI - Rhode Island
SC - South Carolina
SD - South Dakota
TN - Tennessee
TX - Texas
UT - Utah
VA - Virginia
VT - Vermont
WA - Washington (state)
WI - Wisconsin
WV - West Virginia
WY - Wyoming
Outside of the U.S.
Please answer question State before continuing.
What is your zip code? (If you live outside the U.S., please type none.)
Please answer question Zip code before continuing.
Your answer to question Zip code must be a valid U.S. or Canadian Postal Code.
Do you give Eurekafacts permission to text you about research studies?
Please answer question SMS before continuing.
What year were you born?
What is your gender?
Prefer not to answer
Please answer question Gender before continuing.
Are you of Hispanic / Latino origin?
What do you consider to be your racial or ethnic background? (Please select all that apply.)
Black or African American
American Indian or Alaskan Native
Prefer not to answer
Please answer question Ethnic background before continuing.
Please fill in the text box next to the selected choice in question Ethnic background.
Please select at least 1 choices for question Ethnic background.
What is the highest level of education you have completed?
Less than High School Diploma
GED or High School Graduate (Diploma)
What is your annual household income?
Less than $15,000 per year
$15,000 to $24,999 per year
$25,000 to $34,999 per year
$35,000 to $49,999 per year
$50,000 to $74,999 per year
$75,000 to $99,999 per year
$100,000 to $124,999 per year
$125,000 to $149,999 per year
$150,000 to $199,999 per year
More than $200,000 per year
Do you have children?
Are you a Veteran?
Please answer question Veteran before continuing.
Do you have a chronic medical condition?
Please answer question Medical condition before continuing.
Which of the following best describes your job category?
Public sector worker
Sharing information about yourself will help us match you with upcoming paid studies. The more answers you can provide, the better we can match you to paid research studies.
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