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2011
November
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SurveyEpi
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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?
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2024
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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