Participant Enrollment Form

To be considered as a study participant, please fill out the following information. (Required fields have an asterisk *)  Need a copy for a friend?  View a printable version or email your friend a message. Note: Enrollment is limited to United States residents at this time. *First Name *Last Name *City *State: AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashington StateWest VirginiaWisconsinWyoming *Zip *Gender:  Male   Female *Day Phone:   Area Code     Number      extension? *Evening Phone:   Area Code    Number      extension? Cell Phone:   Area Code     Number      1. We primarily notify people about upcoming studies through email, which is our most efficient communication method. If we may contact you in this manner, what is your email address?  1b. For verification, please enter your primary e-mail address again: 1c. Do you have an alternate e-mail address that we should use in case we are ever unable to send a message to your primary address? 1d. Please specify whether you want to be sent email about studies that involve coming to locations in the Greater DC area or just things that you can do from your home/office. Please select one...All Studies - Greater DC & home/officeOnly studies from home or office *2. What is the highest level of education you have completed? Please select one... Less than High School GED High School Associates Trade School Some College Bachelors Masters Degree J.D. Ph.D. M.D. Other Doctorate Level Other Advanced Degree *3. What is your current marital status? Please select one... Single, Never Married Married Engaged Living with sig. other Divorced Separated Widowed * 4. What is your native language? *5. How would you describe your employment status? To select more than one item, hold down the control key. Full-Time Employee Part-Time Employee Self-Employed Student Homemaker/Caring for Children Unemployed-Not Seeking Employment Unemployed-Seeking Employment Retired Disabled - Unable to Work *6. What is your primary occupation? 7. In what industry are you employed? 8. If you are a student, please provide the following additional information: 8a. If you are a student, are you full-time or part time? Please select one... Full-Time Part-Time 8b. What is your academic major or area of study? 8c. What is your expected graduation date or point when you will complete your studies? 8d. What degree are you seeking? *9. What is your month of birth? JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember *9b. What is your year of birth? 10. Which of the following most closely reflects your racial and/or ethnic origins? Please Select One... Black/African-American American Indian or Alaska Native Asian or Pacific Islander Asian - Indian Spanish/Hispanic/Latino White/non-Hispanic Other *11. Do you have any children under 18?  Yes  No 11b. What is/are the birth years of your children who are under 18? #1:N/A2010200920082007200620052004200320022001200019991998199719961995199419931992   #2:N/A2010200920082007200620052004200320022001200019991998199719961995199419931992   #3:N/A2010200920082007200620052004200320022001200019991998199719961995199419931992   #4:N/A2010200920082007200620052004200320022001200019991998199719961995199419931992   #5:N/A2010200920082007200620052004200320022001200019991998199719961995199419931992 12. Sometimes our studies require users who have a disability that will impact their usage of technology, particularly vision difficulties such as colorblindness, low vision, blindness (particularly if you use a screen reader), hearing impairment, mobility impairment, or learning disabilities (such as dyslexia). If you have these or other disabilities, please describe below: *13. Most testing sessions are videotaped to assist in data collection. Are you willing to be videotaped? (You must be willing to be videotaped in order to be recorded in our database).       Yes   No 14. Where did you learn about us? Please select one... Website Link - From where? --> From Friend or Family - Provide Name --> From a co-worker/colleague - Provide Name --> Other - Please Provide Details -->       Please provide details   We often select participants for particular studies based on demographic or other characteristics. Please be assured that all personal information and project data that you supply will be treated as STRICTLY CONFIDENTIAL.