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* Email Address
   
 
 
 
Multiple Choice (select many)
 
ans1
 
ans2
 
ans3
 
ans4

 
 
 
comment box
   
 
 
 
Drop down menu
 
 
 
rank order
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scale2
scale3
 
 
 
* How many hours a day do you spend on:
Working
Reading
Watching TV
Studying
Other
Values must add up to 200
 
 
Multipoint scale
Strongly Disagree Disagree Undecided Agree Strongly Agree N/A
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Multi-point scales (spreadsheet)
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Contact Information
* First Name : 
* Last Name : 
Address 1 : 
Address 2 : 
City : 
State : 
Zip : 
Phone : 
* Email Address : 
 
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