Juneteenth Renaissance Institute- Survey & Focus Group Sign-up

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* 1. Name

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* 2. Email

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* 3. Phone

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* 4. Please choose which option(s) you're interested in

Paid Survey (Majority multiple choice/limited input. $25 each survey. 1-2 hours each survey. Online, hard copy option)

Paid Focus Group (Maximum input/discussion based. $100 per session. 4 hours each session, in person).

I would like to donate my time and do the survey for free

I would like to donate my time and be apart of the focus group for free

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* 5. What is your gender?

Female

Male

Other (specify)

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* 6. What is your age?

17 or younger

18-20

21-29

30-39

40-49

50-59

60 or older

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* 7. What is the highest level of school you have completed or the highest degree you have received?

Less than high school degree

High school degree or equivalent (e.g., GED)

Some college but no degree

Associate degree

Bachelor degree

Graduate degree

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* 8. Which of the following categories best describes your employment status?

Employed, working 40 or more hours per week

Employed, working 1-39 hours per week

Not employed, looking for work

Self-Employed, working 40 or more hours per week

Self-Employed, working 1-39 hours per week

Stay at home parent, homemaker

Retired

Disabled, not able to work

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* 9. How much total combined money did all members of your HOUSEHOLD earn last year?

$0 to $9,999

$10,000 to $24,999

$25,000 to $49,999

$50,000 to $74,999

$75,000 to $99,999

$100,000 to $124,999

$125,000 to $149,999

$150,000 to $174,999

$175,000 to $199,999

$200,000 and up

Prefer not to answer

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* 10. Are you White, Black or African-American, American Indian or Alaskan Native, Asian, Native Hawaiian or other Pacific islander, or some other race?

White

Black or African-American

American Indian or Alaskan Native

Asian

Native Hawaiian or other Pacific Islander

From multiple races

Some other race (please specify)

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* 11. Are you Black and mixed with some other "race"?

White

No, I just identify as Black or African-American

American Indian or Alaskan Native

Asian

Native Hawaiian or other Pacific Islander

From multiple races

Some other race (please specify)

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* 12. Are you Mexican, Mexican-American, Chicano, Puerto Rican, Cuban, Cuban-American, or some other Spanish, Hispanic, or Latino group?

I am not Spanish, Hispanic, or Latino

Mexican

Mexican-American

Chicano

Puerto Rican

Cuban

Cuban-American

Some other Spanish, Hispanic, or Latino group

From multiple Spanish, Hispanic, or Latino groups

Juneteenth Renaissance Institute- Survey & Focus Group Sign-up

Question Title

* 1. Name

Question Title

* 2. Email

Question Title

* 3. Phone

Question Title

* 4. Please choose which option(s) you're interested in

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* 5. What is your gender?

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* 6. What is your age?

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* 7. What is the highest level of school you have completed or the highest degree you have received?

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* 8. Which of the following categories best describes your employment status?

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* 9. How much total combined money did all members of your HOUSEHOLD earn last year?

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* 10. Are you White, Black or African-American, American Indian or Alaskan Native, Asian, Native Hawaiian or other Pacific islander, or some other race?

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* 11. Are you Black and mixed with some other "race"?

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* 12. Are you Mexican, Mexican-American, Chicano, Puerto Rican, Cuban, Cuban-American, or some other Spanish, Hispanic, or Latino group?

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* 13. In what ZIP code is your home located? (enter 5-digit ZIP code; for example, 00544 or 94305)

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* 14. What county do you live in?