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You're in the right place to join one of the most exciting research panels in the U.S.

Please spend just a few minutes telling us about yourself so that we can match you with an upcoming project.

First Name *

Last Name *

Email *

Phone *

Gender *

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Date of birth *

Housing Status *

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Housing Type *

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Address *

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Marital Status *

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Children Living in Home *

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Household Income *

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$15K-$24,999
$25K-$34,999
$35K-$44,999
$45K-$54,999
$55K-$64,999
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$75K-$99,999
$100K-$149,999
$150K-$199,999
$200K-$249,999
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$400K-$449,999
$450K-$499,999
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Highest Level of Education *

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Employment Status *

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Ethnicity *

African American / Black

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Currently Work in Healthcare Industry?

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I do not work in the healthcare industry
Acupuncture / Holistic Treatments
Allied Health Professional (OT, PT, LMT, SLP, etc.)
Chiropractor / Alternative Medicine
Dentistry
EMT / Paramedic
Healthcare Administration
Healthcare Support Staff (Scheduling, Billing, Phlebotomy, Nursing Assistant, Technologist, Hospital Technician, etc.)
Hospital Executive, Director or Manager
Managed Care Executive
Marriage & Family Therapy / Counseling / Mental Health Counselor
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Nurse
Nurse Practitioner
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Podiatry – Wound Care
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Employment Industry

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Construction Occupation

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Plumber

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Lifestyle Interests

I care about financial planning

I am a patient

I love technology

I am a caregiver

I am a parent

I am a smoker

I make business decisions

I have pets

I love cars

I shop frequently

I am a gamer

None of the above

Suffer from Urinary Incontinence

Yes

No

Wear Glasses / Contacts

Yes, readers only

Yes, prescription

No

INTERNAL USE ONLY [Respondent ID] *

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