Screen Reader Mode Icon Check SCREEN READER MODE to make this survey compatible with screen readers. Screening Form Please tell us a little bit about yourself by answering the following questions. OK Question Title * 1. Your first name OK Question Title * 2. Your last name OK Question Title * 3. Your email address OK Question Title * 4. In which U.S. state or territory do you currently live in? Please select your response from the dropdown list below. Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia (DC) Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming OK Question Title * 5. What is your age? Please select your response from the dropdown list below. 17 or younger 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 or older OK Question Title * 6. What is your gender? Male Female Other OK Question Title * 7. Which of the following racial/ethnic group do you identify with? African American Caucasian East Asian or Pacific Islander Hispanic Middle Eastern or North African Native American South Asian OK Question Title * 8. Are you legally blind? Yes No I do not know OK Question Title * 9. At what age (in years) did you first experience difficulty seeing? Please select your response from the dropdown list below. 3 and under 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Over 60 OK Question Title * 10. Which of the following best describes your current employment status? Never looked for employment or self-employment Have only been self-employed Never been employed but seeking work Previously employed and currently seeking work Previously employed and not seeking work Currently employed OK Question Title * 11. Have you ever received disability benefits? Yes No I do not wish to disclose OK We will review your responses and get back to you by email. Thank you for your interest. OK DONE