Gender What is your gender? Male Female Non-Binary Transgender I prefer not disclose I prefer to self-identify Gender Self-Identification Disability Yes No Prefer not to disclose General Ethnic Identification Categories (check as many as apply) What is your race or ethnicity? Check all that apply. Amerian Indian/Alaska Naive Black or African American Native Hawaiian/Pacific Islander Asian Hispanic or Latino White Middle Eastern, Arab, or North African White I prefer not to answer I prefer to self-identify Race or Ethnicity Self-Idenification Country of Birth Language Spoken at Home English Spanish Punjabi Tagalog Ukranian Chinese Vietnamese Dari Prefer not to disclose Other Other Language Spoken at Home Age Group What age group do you belong to? Under 18 18-24 25-34 35-44 45-54 55-64 65+ Prefer not to disclose Income What is your household income? Less than $25,000 $25,000 - $74,000 $75,000 - $124,000 $125,000 - $174,000 $175,000 - $199,000 $200,000+ Prefer not to disclose Leave this field blank Submit
