Epidemiological Study Demographics Form
First Name
Last Name
Gender
Female
Male
Other
Prefer not to say
Age
Ethnicity
Asian
Black or African Descent
Hispanic or Latino
Native American
White
Mixed
Other
Prefer not to say
Education Level
Less than high school
High school diploma or equivalent
Some college
Bachelor’s degree
Postgraduate degree
Other
Employment Status
Employed
Unemployed
Student
Retired
Homemaker
Other
Annual Household Income
Less than $20,000
$20,000 - $49,999
$50,000 - $99,999
$100,000 - $199,999
$200,000 or more
Prefer not to say
Place of Residence (City/Region, Country)