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Participant Background Questionnaire

We welcome you to join regardless of where you are located; however, please note that the majority of our research is conducted in the Raleigh-Durham area of North Carolina and in our new office in the Chicago area.

It is very important that you provide an email you check frequently since studies fill very quickly. We also suggest that you make our recruiter's email address (psnow@humancentric.com) a "safe sender" in order to ensure you will receive those invitations.

Contact Information

First Name:
Last Name:
Home Phone:
Work Phone:
Mobile Phone:
Address 1:
Address 2:
City:
State:
Zip Code:
Country:

Personal Information

Gender:	Male Female
Year of Birth (do not enter complete DOB):
Height:
Dominant Hand:	Right Left Ambidextrious
What is your highest level of education completed?	Grade School Some High School Completed High School / GED Completed vocational or technical degree Some college 4 year college degree Some post graduate college Master's degree Doctorate

Occupational Information

What is your job title, occupation or major field of study?
In what industry do you work?
What is the name of your company or school?
Are you a business owner?	Yes No
Number of Employees:
Are you in the medical field?	Yes No
If you are in the medical field, what is your occupation?	Nurse EMT MD Pharmacist Other

Other Information

What is your primary email address? Please make sure the email you provide is one you check frequently and that you make our recruiter's email (psnow@humancentric.com) a "safe recipient."
What is your secondary email address?
Do you live close to either our office in Cary, NC or our office in Chicago, IL?	Yes No