Step 1

Demographic questions 

OPO collects demographic information to identify disparities and ensure that our community outreach is equitable and inclusive. Your identity will remain anonymous.

What is your age in years? Please specify in number form. #:

Closed to responses

What zip code do you reside in?

What zip code do you work in?

Do you consider yourself to be a part of the LGBTQ community?

Yes
No
Prefer not to answer
Closed to responses

With which gender do you identify?

Woman
Man
Transgender Woman/ Trans Feminine
Transgender Man/ Trans Masculine
Non-Binary / Genderqueer / Gender Fluid
Two Spirit
Prefer to self-describe
Prefer not to answer
Closed to responses

Do you live with a physical or mental health condition? Or have you been diagnosed with a disability? (Examples: hearing loss, ADHD, depression, epilepsy, lupus)

Yes
No
Prefer not to answer
Closed to responses