Thank you for taking the time to answer these questions. By doing this you will be able to help us in the future with pretesting. Pretesting is when you provide reactions or responses to a brochure, flyer, or other printed material. This helps us make things that are good-looking, that make sense, and that meet the needs of the people it is meant for. For this we will send you a $10 gift card. Your contact information will be kept private in a secure file and will not be shared. We will only contact you when we have messages/materials for you to review, this happens once we have created something new. Then you will get an email with the messages/materials and 7 questions to answer. After you return your answers, you will be given a $5 gift card for your time. Each time you review our messages/materials will get you a new $5 gift card.
What is your name?
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What is the physical home address that you receive mail at? This is how you receive mail including incentives from Public Health Sauk County.
What is the physical home address that you receive mail at? This is how you receive mail including incentives from Public Health Sauk County.
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is the best phone number to reach you?
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What is your email address?
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What town do you live in?
Select the range that best describes your age:
*
Please Select
18-25
26-35
36-50
50-64
65+
Prefer not to answer
What is the highest degree or level of school completed?
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Please Select
None
Grade 8 or below
Some high school
High school diploma
GED or equivalent
Some college but no degree
Associates Degree
Bachelors Degree
Some Graduate courses but no degree
Graduate Degree
Prefer not to answer
What is your marital status?
*
Please Select
Married
Widowed
Divorced
Separated
Never married
Living with partner but not married
Don't know
Prefer not to answer
Are you of Hispanic or Latino/Latina/Latinx ethnicity?
*
Please Select
Yes
No
Don't know
Prefer not to answer
Which of the following would you use to describe your primary racial identity?
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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
What language(s) do you usually speak at home? (Choose all that apply)
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English
Spanish
Don't know
Prefer not to answer
Other
What was your sex assigned at birth?
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Please Select
Male
Female
Don't know
Prefer not to answer
Do you consider yourself to be
*
Please Select
Woman
Man
Transgender
Non-binary/non-conforming
Prefer not to answer
Do you have one or more child(ren)
*
Please Select
Yes
No
Don't know
Prefer not to answer
Did you ever breastfeed your child?
*
Please Select
Yes
No
Don't know
Prefer not to answer
Not applicable
Do you feel like you can access and afford childcare if you need it?
*
Please Select
Yes
No
Don't know
Prefer not to answer
Not applicable
Are you a current or past participant of Nurse Family Partnership (NFP), Women, Infants & Children (WIC) or Prenatal Care Coordination (PNCC)?
*
Please Select
Yes
No
Don't know
Prefer not to answer
Have you or a loved one ever struggled with substance use?
*
Please Select
Yes
No
Don't know
Prefer not to answer
Have you experienced challenges with mental/emotional health and/or wellbeing?
*
Please Select
Yes
No
Don't know
Prefer not to answer
Do you own the place where you currently live, including currently paying a mortgage?
*
Please Select
Yes
No
Don't know
Prefer not answer
Do you consider yourself to be a farmer or in the agriculture industry?
*
Please Select
Yes
No
Don't know
Prefer not to answer
Please verify that you are human
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Submit
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