1. What is your age?
13 or younger. 14 - 16. 17 - 21. 22 - 25. 26 - 32. 33 - 40. 41 - 55. 56 - 66. 67 - 75. 76 and over.
2. Gender?
Male. Female.
3. What is your ethnicity? (Choose the answer that best describes you)
Asian. Black/African descent. Caucasian/white. Latino/Hispanic. East Indian. Middle Eastern. Native American. Pacific Islander. Other.
4. What is your sexual orientation?
Heterosexual. Gay/lesbian. Bi-sexual.
5. What month were you born?
January. February. March. April. May. June. July. August. September. October. November. December.
6. In which State do you currently reside?
Maine, New Hampshire, Vermont, New York, Massachusetts, Rhode Island or Connecticut? Pennsylvania, New Jersey, Delaware, Maryland or Washington DC. Virginia, West Virginia, North Carolina, South Carolina, Georgia or Florida. Wisconsin, Illinois, Michigan, Indiana or Ohio. Kentucky, Tennessee, Mississippi or Alabama. North Dakota, South Dakota, Nebraska, Minnesota or Iowa. Kansas, Missouri, Oklahoma, Arkansas or Texas. Montana, Wyoming, Utah, Colorado, Arizona or New Mexico. Alaska, Washington, Oregon, California, Idaho, Nevada or Hawaii. Outside of the U.S.
7. Employment.
Never been employed. Recently unemployed. Unemployed for 6 mos. or longer. Recently employed. Employed 3 or more years for the same company. Self-employed. Retired.
8. Occupation.
Administrative/secretarial. Artist/musician/writer. Executive/management. Finance. Food services. Labor/construction. Legal. Medical/dental. Military. Political/government. Retired. Sales and marketing. Self-employed. Student.
9. Do you enjoy your job?
Yes. No. Unsure. N/A.
10. Schooling.
Drop-out. Still in high school. General education diploma (GED). High school diploma. Some college. Associate's degree. Bachelor's degree. Master's degree. PhD/doctoral.
11. Have you ever been married?
Yes. No.
12. Ever been divorced?
Yes. No.
13. Are you currently in a relationship?
Yes. No.
14. Were your parents ever married to each other?
Yes. No. I don't know.
15. How many siblings do you have?
None. 1. 2 - 3. 4 - 5. 6 or more.
16. Do you own any pets?
Yes. No.
17. Do you have any children?
Yes. No.
18. Do you use illicit substances/narcotics?
Never. Occasionally/socially. Regularly engage in a single illicit substance. Regularly engage in multiple illicit substances.
19. Do you drink alcohol?
No. Occasionally/socially. Regularly.
20. Do you use chewing tobacco, cigarettes, cigars or pipe tobacco?
No. Occasionally/socially. Regularly.