Exit this survey Questionnaire for Discussion Groups Question Title * 1. Please provide some basic information about yourself. Name: * ZIP: * Email Address: Phone Number: * Question Title * 2. Are you male or female? Male Female Question Title * 3. What is your age? Under 16 16 to 29 30 to 44 45 to 59 60 and above Question Title * 4. Which of the following best describes your racial or ethnic group? African-American Asian Caucasian, European, or white Hispanic or Latino Other Other (please specify) Next