Please verify your information – Medford and Bend

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Name*

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Email*

Please enter the email you have with us.

Enter Email Confirm Email

Best Contact Phone Number*

What is the best number to contact you at via phone?

What year were you born*

Enter the year you were born, like 1999 or 1972.

Please enter a number from 1900 to 2050.

Gender*

Which best describes the gender to which you most identify?

-- SELECT BELOW --MaleFemaleTransgender FemaleTransgender MaleGender Variant or Non-Conforming

Which County*

Which US County, Parish, or Township do you live in?

-- SELECT BELOW --DeschutesJacksonAnother county not listed

Race/Ethnicity*

What is your race or ethnicity? If you are mixed race, select all races you represent.

African American

Asian

Caucasian

Hispanic or Latino

Middle Eastern

Native American or Alaskan Native

Pacific Islander or Native Hawaiian

Some Other Race

Education*

Which best describes the highest level of education you have had the opportunity to complete?

-- SELECT BELOW --Some high schoolGEDHigh schoolSome college (no certificate)Associates degreeTechnical schoolBachelors degreeSome post graduatePost graduate degree

Occupations*

Do you work in, or have any training in any of the following industries or fields? Select all that apply.

Banking or Finance Fields

Education Fields

Government Fields

Health Insurance Fields

Law Enforcement Fields

Legal Fields

Marketing and Communications Fields

Medical Fields

Mental Health Fields

Military Fields

News and Media Fields

Political Fields

None of the Above

Children at Home*

Do you have any children under the age of 18 at home?

Yes

No

Marital Status*

Which best represents your current marital status?

-- SELECT BELOW --DivorcedLiving with PartnerMarriedSingleWidowed

Household Income*

Which category best represents your family's total household income, before taxes annually?

-- SELECT BELOW --Under $20K$20-$35K$35-$50K$50-$80K$80-$100K$100-$150K$150-$250K$250K or more

Employment Status*

Which best describes your current employment status?

-- SELECT BELOW --Full-timePart-timeSelf-EmployedHomemakerRetiredUnemployedStudentDisabled

Home Ownership*

Own

Rent

I have a different arrangement

Fire Experience*

Have you or has anyone in your immediate family experienced injury or property loss due to a wildfire?

Yes

No

Fire Impact*

Have you been impacted by any of the following: the Beachie Creek, Kimberling, Echo Mountain, 242, Obenchain, Archie Creek or Slater Fires?

Yes

No

Address*

Please enter your mailing address so we can mail you your study information in addition to the email information you will receive from us. Include your CITY, STATE, and ZIP CODE as well.

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