Title
First Name Last Name
Mailing Address
Suite/Apt
City State
Zip Code /Postal Code
Phone (Day) Phone (Evening)
E-mail
Gender
Male Female
Age
Below 13 13-18 19-25
26-35 36-45 46-55
56+
Race
African American White
Hispanic Asian/Pacific Islander
Other
Household Income
Less than $25K 25K-45K
46K-75K 76K-100K 100K +
Highest level of education
Some high school
GED certificate or High school graduate
Some college coursework
Trade or Vocational School Completed
A.A., Junior, or Community College degree
BA, BS, BFA, or equivalent received
Some Graduate school coursework
Graduate school completed
Other
Employment
Employed Self-Employed
Retired Unemployed
Martial Status
Married Single
Divorced Widowed
Household Size
1-4 5-8
Do you own a home?
Yes No
How did you hear about this event?
(complete ALL that apply)
TV Radio Print Ads
Church Internet E-mail
Friend
Do you watch Tavis Smiley on PBS in your area?
Yes No
If yes, on what PBS station?
Do you listen to The Tavis Smiley Show on PRI?
Yes No
Do you volunteer for any Youth Programs in your community?
Yes No
Do you know about the Tavis Smiley Foundation's Youth 2 Leaders Program?
Yes No
How many books have you purchased this year?
None
 1 - 4 5- 10 11-15 16+
What type of books did you purchase?
Fiction Hard cover Paper back
Non Fiction -
Politics/Social Justice Personal Stories
Advocacy
Education
History
Sociology
Autobiography
Biography
Memoir
Self-Help Health
Personal Growth
Inspirational
Spirituality
Religion
Men's Health
Women's Health
Alternative Health/Diet
Family Health
Fitness
Business/Financial Psychology
Entrepreneurship
Management & Leadership
Personal Finance
Personal Transformation
Relationships
Communication
Women's Issues
New Thought
What types of books would you like to purchase geared towards African Americans?
Fiction Hard cover Paper back
Non Fiction -
Politics/Social Justice Personal Stories
Advocacy
Education
History
Sociology
Autobiography
Biography
Memoir
Self-Help Health
Personal Growth
Inspirational
Spirituality
Religion
Men's Health
Women's Health
Alternative Health/Diet
Family Health
Fitness
Business/Financial Psychology
Entrepreneurship
Management & Leadership
Personal Finance
Personal Transformation
Relationships
Communication
Women's Issues
New Thought
Have you tasted any item from a fast food restaurant's healthy menu? (salads, wraps, grilled sandwiches, yogurt, etc ...)
Yes No
Which one?
Do you consider yourself a healthy person?
Yes No
How many fruits and vegetables do you eat per day?
1 2 3 4 5
How many days of exercise do you engage in per week?
1 2 3 4 5 6 7
What types of investments/assets do you have?
Real Estate Stocks/Bonds/Mutual Funds
Jewelry Commodities
Art Annuities/401K/403B
Do you carry life insurance?
Yes No
What represents you've made it?
Luxury car Home ownership
Graduate degree Jewelry
Six-figure job
Do you own/lease an automobile?
Yes No
If so, what make and model
Are you planning to purchase or lease a car/truck/SUV this year?
Yes No
Have you heard about HYBRID vehicles?
Yes No
Would you consider buying a HYBRID vehicle?
Yes No
If you already have a car, did you:
buy a new car buy a pre-owned/used car
receive car as a gift lease a new car/pre-owned car
finance through a bank or credit union
finance through car dealership
finance through third-party finance company
Who is your auto insurance carrier?
How long have you been with your auto insurance carrier?
Less than a year 1-3 years
3-5 years 5-10 years 10+ years
Are you satisfied with your auto insurance provider?
Yes No
Do you have health insurance?
Yes No
Are you satisfied with your health insurance provider?
Yes No
What is your most pressing health concern?
Do you or someone in your family have a history of the following ailments/diseases? (Please select all that apply)
Breast cancer Prostate cancer
Asthma Heart disease
High blood pressure Violence
Obesity HIV/AIDS
Pneumonia Diabetes
Where do you get information about your health concerns?
Internet Television
Radio Medical journals
Neighborhood clinic Doctor
Friends/family Health fairs
Newspapers/magazines
If you could ask one question to any one in the world (dignitary, doctor/scientist, activist, media personality, religious leader, etc.).
Who would you choose?
What is your question? (300 characters or less)
What is your answer to your question? (300 characters or less)
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