Wellness In Action Question Title * 1. Name Question Title * 2. Phone Number Question Title * 3. Email Address Question Title * 4. Which race/ethnicity best describes you? (Please choose only one.) American Indian or Alaskan Native Asian / Pacific Islander Black or African American Hispanic White / Caucasian Multiple ethnicity / Other (please specify) Question Title * 5. What is your sexual orientation? Asexual Bisexual Gay Heterosexual or straight Lesbian Pansexual Queer None of the above, please specify Question Title * 6. What is your gender identity? Woman Man Genderqueer or non-binary Agender Transgender Male Transgender Female Not specified above, please specify Question Title * 7. What is your age? 18 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 or older Question Title * 8. Zip Code Question Title * 9. How did you hear about Self Test? Question Title * 10. If you did not receive a test kit in person do you need one mailed to you? Yes No Question Title * 11. If you answered yes please, provide a shipping address Name Address Address 2 City/Town State/Province ZIP/Postal Code Country Done
