PAPERWORK REDUCTION ACT OF 1995 (Public Law 104-13) STATEMENT OF PUBLIC BURDEN The purpose of this information collection is to help us recruit and engage participants who are representative of the intended audiences for the We Think Twice™ campaign in order to request feedback specific to the campaign. Public reporting burden for this collection of information is estimated to take no more than 10 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a voluntary collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0401 and the expiration date is XX/XX/XXXX. If you have any comments on this collection of information, please contact Kaitlin Dixon at [email protected].
Registration Survey for We Think Twice™ Insider Recruitment
First name
Last name
What is your current gender identity? (Select ALL that apply)
Male
Female
Transgender Male/Transman/FTM
Transgender Female/Transwoman/MTF
Genderqueer
Another category
Prefer not to answer
Date of birth
What sex were you assigned at birth? (Select one)
Male
Female
Prefer not to answer
Zip code
What is your race? (You may select one or more races)
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Don’t know
Prefer not to answer
Other
Are you of Hispanic or Latino origin? (Select one)
Yes
No
What type of school do you attend?
Public
Private
Charter
Boarding
Other
Tell us something about yourself
Age
Gift Card Preference
Starbucks
Amazon
iTunes
For some Insider activities, we’ll be asking about your ideas and experiences. Can we quote you on our website and/or social media page?
Yes, you can quote me anonymously
No, you cannot quote me
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | McIntosh, Chloe |
File Modified | 0000-00-00 |
File Created | 2024-07-25 |