I am:
female male

My age is:
18 years or younger
19 - 30 years
31 - 45 years
46 - 59 years
60 years or older

My ethnicity is:
African American
Asian / Pacific Islander
European / Caucasian
Latina/o
Native American
Multiracial
I choose not to disclose.

My native language is:
English
not English (please specify language)

My educational background is:
High School
Some College
Undergraduate Degree
Advanced Degree

I am a:
person living with serious illness
caregiver
medical professional
social service professional
government official
teacher
member of the clergy
community volunteer

I am currently raising a child(ren) at home:
Yes
No

I am currently providing care for a:
spouse
parent
family member (brother, sister, aunt, uncle, etc.)
friend
neighbor
patient or client
member of my community of faith
no one currently

My insurace coverage is:
Private Insurance/PPO
HMO
Medicare/Medicaid
None

Insurance coverage for the person you are providing care:
Private Insurance/PPO
HMO
Medicare/Medicaid
None

My income level is:
under $20,000
$20,000 - $39,999
$40,000 – $59,999
$60,000 or more

Income level for the person you are providing care:
under $20,000
$20,000 - $39,999
$40,000 – $59,999
$60,000 or more

Employment status for the person you are providing care:
Employed Full Time
Employed Part Time
Does not work outside home
Leave of Absence to provide care
Unemployed
Retired
Disabled

My employment status:
Employed Full Time
Employed Part Time
Do not work outside home
Leave of Absence to provide care
Unemployed
Retired
Disabled

I am interested in caregiving information focused on (check all that apply):
HIV/AIDS
cancer
elder care
COPD/CHF (chronic obstructive pulmonary disease, congestive heart failure)
brain tumors
family caregiving
faith-based caregiving
volunteer caregiver programs
professional (paid) home care services
other (please specify )