Personal Data
First Name
Last Name
Street Address:
City:
State:
Zip Code:
Home Telephone number :
E-mail:
Gender:
Male
Female
Birth Date
(mm/dd/yy)
:
/
/
Education Level
(in years or by degree)
:
Ethnicity :
African-American
Not Required
Native-American
Asian
Caucasian
Hispanic
Other
Vision Problems :
Do you have any problems reading newspaper size print?
Medications:
Are you currently taking any medications that could make you drowsy and possibly unable to participate well in an experiment that required your attention?
Dexterity Problems:
Do you have any problems (such as arthritis) that may make it difficult to write or use a computer keyboard?
Experiment Availability:
When is the best time for you to come in to do and experiment (generally)
Facility Choice:
Which facility would you be most interested in participating at
Georgia Tech
Marietta Site
Transportation:
Do you have means to get to our facilities?
Yes
No
Are you a US Citizen or Permanent Resident:
Yes
No
If not, please list Country of Citizenship:
Thank you for your interest.