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Hello:
You are invited to participate in our survey assessing health status and perceptions of government.

Your participation in this study is completely voluntary. There are no foreseeable risks associated with this project. However, if you feel uncomfortable answering any questions, you can withdraw from the survey at any point.

Your survey responses will be strictly confidential and data from this research will be reported only to research staff. Your information will be coded and will remain confidential.

Thank you very much for your time and support. Please start with the survey now by clicking on the

 
 
 
What is your date of birth?
 
 
 
Are you male or female?
 
Male
 
Female
 
 
 
Which of the following best describes your current employment status?
 
Working full time now
 
Working part time now
 
Temporarily laid off
 
Unemployed
 
Retired
 
Permanently disabled
 
Taking care of home or family
 
Student
 
Other
 
 
 
Which racial or ethnic group best describes you?
 
White
 
Black or African-American
 
Hispanic or Latino
 
Asian or Asian-American
 
Native American
 
Mixed Race
 
Middle Eastern
 
Other
 
 
 
What is your marital status?
 
Married, living with spouse
 
Separated
 
Divorced
 
Widowed
 
Single, never married
 
Domestic Partnership
 
 
 
What is the highest level of education you have completed?
 
Did not graduate from High School
 
High school graduate
 
Some college, but no degree (yet)
 
2-year college degree
 
4-year college degree
 
Post-graduate degree (MA, MBA, MD, JD, PhD, etc.)
 
 
 
How would you describe your sexual orientation?
 
Heterosexual
 
Homosexual
 
Bisexual
 
Transgender
 
 
 
How many individuals live in your household?
   
 
 
 
Are you covered by health insurance or some other kind of healthcare plan?
 
Yes
 
No
 
Don't Know
 
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