Research recruitment form

Contact Details

First name *

Surname *

Title *

Street address 1 *

Street address 2

Suburb *

State

Victoria New South Wales Queensland Northern Territory Western Australia South Australia Tasmania Australian Capital Territory

Postcode *

Telephone (H) *

Telephone (M) *

Telephone (W) *

Email *

Email check frequency

A few times an hour Every few hours (e.g. 2-4 hrs) Twice a day Daily Every few days Not applicable / Do not have an email address Other

Preferred contact method

Other Telephone - mobile number Telephone - home number Telephone - work number Email

Personal Details

Marital status

Other De facto Divorced Engaged Married Separated Single Widowed

No. of children *

Date of birth

Gender

Male Female Other

Annual household income

Less than $10,000 $10,000 to $19,999 per year $20,000 to $29,999 per year $30,000 to $49,999 per year $50,000 to $69,999 per year $70,000 to $89,999 per year $90,000 to $149,999 per year $150,000 or more per year

Household type

Person living alone Couple only Couple with non-dependent child/ren Couple with dependent child/ren Couple with dependent and non-dependent child/ren Single parent with non-dependent child/ren Single parent with dependent child/ren Single parent with dependent and non-dependent children Non-related adults sharing house/apartment/flat Related adults sharing house/apartment/flat, e.g with siblings Other

Main language spoken at home *

Any other language spoken fluently

Country of birth *

Are you of Aboriginal or Torres Strait Islander origin?

Yes No Don't know

Residency status

Australian citizen Permanent resident Temporary resident (student visa) Temporary visa (business) Other

If you have moved to Australia to live (either permanently or temporarily), in what year did you arrive?

If you are living in Australia with a visa, please name the type of visa you are on:

Employment information

Employment status

Employed full-time Employed part-time Currently unemployed Student Retired Home duties Self-employed Other

If you are employed, please provide your current job title

If you are currently employed, please provide the industry you work in

If you are currently employed, what is the size of your employer?

N/A Between 1-20 employees Between 21-60 employees Between 61-100 employees Over 100 employees Don't know / unsure Other

Employer's postcode

Education information

Highest level of education completed

Year 10 (school certificate) Year 12 (high school certificate) Certificate I, II or III Certificate IV Advanced Diploma or Diploma Undergraduate Degree Graduate Diploma or Graduate Certificate Postgraduate Degree Doctorate

Education institute type (where highest level of education was completed)

Secondary school (public) Secondary school (private) TAFE institute Private provider University Other Unsure / don't know

Education course field (e.g. engineering, plumbing)

Are you currently studying?

Yes No

What is the title of the course you are currently studying?

Medical and physical health information

Do you have any current medical conditions?

Yes No Prefer not to say

If you do, what current medical conditions do you have?

Do you drink alcohol?

Yes No

Do you smoke tobacco products?

Yes No

Final question

How did you find out about us?

Search engine Social Network Advertisement Friend Forum or blog Other

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