Please Share YOUR Demographic information
Gender Male Female Transgender Other Are you Hispanic? Yes No Race American Indian Asian Black/African American Hawaiian/Pacific Islander White Other Income Level Less than $25,000 $25,000 to $34,999 $35,000 to $49,999 $50,000 to $74,999 $75,000 to $99,999 $100,000 to $149,999 $150,000 or more Age range of Person At-Risk: Under 20 20 to 30 31 to 40 41 to 50 51 to 60 over 60 Have you served in the military? Yes No
Is this a replacement kit?
No value selected Yes (complete info below) No (skip this section) If yes, what happened to the previous kit?
No value selected Lost/Stolen Kit Expired Kit Broken Kit Kit given to someone else Administered/Used I don’t know Other Did it work?
No value selected Yes No Was 911 called?
No value selected Yes No, because... If the kit was administered complete as much of the information as you can.
Gender No value selected Male Female Transgender Other
Hispanic/Latino No value selected Yes No
Race No value selected American Indian Asian Black/African American Hawaiian/Pacific Islander White Other
Income Level No value selected Less than $25,000 $25,000 to $34,999 $35,000 to $49,999 $50,000 to $74,999 $75,000 to $99,999 $100,000 to $149,999 $150,000 or more
Age range of Person At-Risk: No value selected Under 20 20 to 30 31 to 40 41 to 50 51 to 60 over 60
Have (s)he served in the military? No value selected Yes No Zip Code or County (if zipcode isn't known)
800.522.9054 
TEXT 55155 
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