• First Name
• Last Name
• Street Address
• Street Address 2
• City
• State or Territory
• Mobile Phone
• Home Phone
• Other Phone
• Personal Email
• Other Email
• Preferred Method of Contact
• Date of Birth
• Are any of these a closer description of how you think of yourself?
• Specify your description of how you think of yourself
• Since the start of the COVID-19 pandemic (March 2020), have you needed to postpone any medical care?
• Have you completed the COVID-19 vaccination course? Most COVID-19 vaccines require two shots.
• How confident are you that a negative test result means that you do not have COVID-19?
• How confident are you that a positive test result means that you do have COVID-19?
• Reduce worry that I might have COVID-19.