UserWorks, Inc.

1738 Elton Rd., Suite 138, Silver Spring, MD 20903
(301) 431-0500
(301) 431-4834 (fax)
info@userworks.com

After completing this form, please send it to UserWorks by mail or fax. Alternatively, you can fill this form out online, by going to our website at http://www.userworks.com

To be considered as a study participant, please fill out the following information. (Required fields have an asterisk *)

Note: Enrollment is limited to United States residents at this time.

*First Name	*Last Name
*City	*State:
*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.

*2. What is the highest level of education you have completed?

*3. What is your current marital status?

* 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.

*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?

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?
*9b. What is your year of birth?

10. Which of the following most closely reflects your racial and/or ethnic origins?

*11. Do you have any children under 18? Yes No

11b. What is/are the birth years of your children who are under 18?

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 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.