Demographics Survey

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0

Where do you live?
0

What is your age?
< 18 years

18 - 25 years

26 - 50 years

51 - 65 years

> 65 years
0

What is your gender?
Male

Female

Other (Please Specify)
0

What is your ethnicity?
0

What is your religion?
0

What is your highest education level?
0

What is your profession?
0

What is your marital status?
Single

Attached

Married

Divorced

Widowed

Other (Please Specify)
0

What is your household size?
1

2

3

4

5

> 5
0

What is your household income?
< $10,000

$10,000 - $20, 000

$20,001 - $30, 000

$30,001 - $50, 000

> $50,000