Outreach Survey

1. What is your home zip code?

• Other - Write In Please enter an 'other' value for this selection.

2. How many people live in your home?

• Other - Write In Please enter an 'other' value for this selection.

3. What age range do you fall under?

• Under 20
• 21-30
• 31-40
• 41-50
• 51-60
• 61-70
• 71 or older

4. What is your race?

• American Indian or Alaska Native
• Asian
• Black or African American
• Native Hawaiian or other Pacific Islander
• White
• Other - Write In Please enter an 'other' value for this selection.

5. What is your ethnicity?

• Hispanic or Latino or Spanish Origin
• Not Hispanic or Latino or Spanish Origin

6. What is your primary language?

• English
• Spanish
• Tagalog
• Other - Write In Please enter an 'other' value for this selection.

7. What is your sex at birth?

• Female
• Male

8. What is your highest level of education?

• Less than High School
• Some High School
• High School Degree/GED (or equivalent)
• Some College (no degree)
• Associate Degree
• Bachelor's Degree
• Graduate or Professional Degree

9. What is your employment status?

• Full-time
• Part-time
• Retired
• Student
• Unemployed

10. What was your total income last year, before taxes?

• Less than $20,000
• $20,001-$40,000
• $40,001-$60,000
• $60,001-$80,000
• $80,001-$100,000
• Over $100,000

11. What type of health insurance do you have?

• Medicaid
• Medicare
• Private/Commercial
• Tricare or VA
• I do not have insurance.