Example Registration Form

Women’s Health Awareness Day 2016 Registration

OMB # 0925-XXXX

Expiration Date: XX/XXXX

Public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-xxxx).  Do not return the completed form to this address.

First Name:*

Last Name:*

Preferred Email:*

Preferred Phone Number:*

Cell Phone Number:

Address:*

City:*

State:*

Zip Code:*

Age:*

• Under 21 years of age

• 21-30

• 31-40

• 41-50

• 51-60

• 61 and above

Gender:*

• Female

• Male

Are you Hispanic/Latino?*

• Yes

• No

Select one or more of the following races:*

• American Indian or Alaska Native

• Asian

• Black or African American

• Native Hawaiian or Other Pacific Islander

• White

What is the highest degree or level of school you have completed? If currently enrolled, highest degree received.*

• No schooling completed

• Nursery school to 8th grade

• Some high school, no diploma

• High school graduate, diploma or the equivalent (for example: GED)

• Some college credit, no degree

• Trade/technical/vocational training

• Associate degree

• Bachelor’s degree

• Master’s degree

• Professional degree

• Doctorate degree

Marital Status:*

• Single, never married

• Married or domestic partnership

• Widowed

• Divorced

• Separated

Employment Status:*

• Employed for wages

• Self-employed

• Out of work and looking for work

• Out of work but not currently looking for work

• A homemaker

• A student

• Military

• Retired

• Unable to work

Annual Household Income:*

• Less than $10,000

• $10,000 to $19,999

• $20,000 to $29,999

• $30,000 to $39,999

• $40,000 to $49,999

• $50,000 to $59,999

• $60,000 to $69,999

• $70,000 to $79,999

• $80,000 to $89,999

• $90,000 to $99,999

• $100,000 to $149,999

• $150,000 or more

Did you attend Women’s Health Awareness Day 2015?*

• Yes

• No

I am interested in participating in:*

• Full day, including workshops and receiving health services

• Morning workshops

• Afternoon workshops

• Health services

• Other

How did you hear about this event?*

• Family/Friend

• Social media

• Listserve

• Newspaper

• Other:

Do you have any special accommodation needs?*

• Yes

• No

If so, please let us know what they are.

Do you require Spanish interpreter services?*

• Yes

• No

Do you require Handicapped Parking?*

PLEASE NOTE: Handicapped Parking require Official NC Handicap Decal

• Yes

• No

Level of participation*

• Participant

• Volunteer

• Speaker

• Interpreter

• Exhibitor

Are you a member of:

Delta Sigma Theta Sorority, Inc.

• Chapter:

Latinas Promoviendo Comunidad/Lambda Phi Chi Sorority, Inc.