Caregivers
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First name *
Last name *
Best number to call *
Best number to text *
Who is your cell phone provider? *
Email address *
Age *
Gender *
Ethnicity *
Required
Marital status *
Employment *
What industry do you work in? *
What is your job title? *
Do you or does anyone in your household currently work for or have ever worked for any of the following? *
Required
What is your highest level of education that you have completed? *
What is your combined annual household income before taxes? (By this we mean all income brought into by anyone living there combined) *
Are you currently a caregiver to anyone? *
Is the person you are a caregiving for currently or previously a smoker of cigarettes (even socially)?
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How old is the person you are a caregiver for? *
What is the gender of the person you are a caregiver for? *
If you are an acting caregiver for anyone inside or outside the home please indicate your relationship to that person *
If you are an acting caregiver for anyone inside or outside the home please indicate what they have been diagnosed with or why you are a caregiver for them *
If, you mentioned Cancer, what specific type of Cancer does the person have? *
If you mentioned Cancer, what Stage cancer? *
What are some of your responsibilities as acting caregiver? *
How long have you been their caregiver? *
How long has the person you are caring for been diagnosed with their condition or ailment? *
What state do you live in? *
If you are not a caregiver have you, yourself been diagnosed with anything by a physician? *
What county do you live in? *
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