CPT Participant Survey – The Audacia Foundation, Inc.

To All CPT Participants

The New York State Department of Health (NYSDOH), as part of the CPT program, is collecting demographic information about participants and we need some additional information from you to comply with this request.

The collected information that is reported to NYSDOH will be anonymized and will not be personally identifiable.

X/Twitter

This field is for validation purposes and should be left unchanged.

Personal Information

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Your Name

First Last

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Your Email Address

Enter Email Confirm Email

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CPTID(Required)

County of Residence(Required)

Year of Birth(Required)

Household Size(Required)

Average Household Income(Required)

Gender(Required)

Sexual Orientation(Required)

Race(Required)

Race Other(Required)

Ethnicity Other(Required)

Ethnicity(Required)

Ethnicity Other(Required)

Ethnicity(Required)

Ethnicity Other(Required)

Ethnicity(Required)

Ethnicity Other(Required)

Ethnicity(Required)

Ethnicity Other(Required)

Ethnicity(Required)

Ethnicity Other(Required)

Ethnicity(Required)

Ethnicity Other(Required)

Ethnicity(Required)

Ethnicity Other(Required)

Current Employment

Are you currently employed?(Required)

Yes

Is your current employment in healthcare?(Required)

Yes

Are you working full-time or part-time?(Required)

Full-time

Part-time

Employer Name(Required)

Job Title(Required)

Salary(Required)

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