Consumer Panel Update

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Question Title

* Contact Information

Name *

Address *

Address 2

City/Town *

State *

ZIP/Postal Code *

County *

Email Address *

Phone Number {cell} {other} *

Question Title

* Do you have children?

Yes, living in the same household

Yes, but not living in the same household

Question Title

* Which best describes your current employment status:

Employed full time

Employed part time

Homemaker

Retired

Disabled

Not employed

Other (please specify)

Question Title

* What is the highest level of education you have achieved?

Less than high school graduate

High school graduate

Some college or technical school

College graduate

Graduate school or higher

Question Title

* What do you consider to be your racial or ethnic identity?

Asian/Pacific Islander

Black/African American

Hispanic/Latino

Native American

White/Caucasian

Other (please specify)

Question Title

* Into which category do you estimate your total household income falls?

Under $25,000

$25,000 to under $50,000

$50,000 to under $75,000

$75,000 to under $100,000

$100,000 to under $150,000

$150,000 or more

Other (please specify)

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