One Small Step Questionnaire – CMAC, Fresno (2022) One Small Step Screening Questionnaire - Deprecated Step 1 of 5 0% Name* First Last Location (City, State, ZIP)* City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Address* Preferred phone number*If you are a member of the college community, are you a...? Student Faculty member Alumni College administrator How did you find out about the opportunity to participate in StoryCorps' One Small Step?Please check all that apply. Radio Social media Email Flyer, postcard, or other print advertisement Event A friend, family member, or colleague A group or organization Another way HiddenHow did you find out about the opportunity to participate in StoryCorps' One Small Step? Radio Social media Email Flyer, postcard, or other print advertisement Event A friend, family member, or colleague A group or organization Another way Please specify Terrific! Can you share their name? Great! Which one? Tell us more! Do you know someone you would like to speak with for One Small Step?If you have a conversation partner in mind, we will get in touch with you for further details. No Yes Person's name, and relationship to you Most One Small Step recordings take place online via a video call. Do you have access to a computer or mobile device (iPad, tablet, etc.) and reliable internet? Yes No If not, don't worry! We want to make this opportunity available to everyone, so we will work with you to find another way to participate.Currently, conversations are hosted virtually, but we may conduct recordings in person later this year. How would you prefer to participate? Virtually In-person No preference (comfortable with either) Do you have access to a computer or mobile device (iPad, tablet, etc.) and reliable internet? Yes No If not, don't worry! We want to make this opportunity available to everyone, so we will work with you to find another way to participate. Where on this scale would you place your thinking on social issues?Drag the slider to where you feel you fit best on the scale, with the left being the most liberal and the right the most conservative. I would not place myself on this scale.Please briefly describe your thinking on social issues. Where on this scale would you place your thinking on economic issues?Drag the slider to where you feel you fit best on the scale, with the left being the most liberal and the right the most conservative. I would not place myself on this scale.Please briefly describe your thinking on economic issues. How important is religion in your life?Drag the slider to where your feelings on religion fit best on the scale, with the left being not at all important and the right extremely important.Are you a registered voter in the US? Yes No Prefer not to answer Which party are you registered with, if any? Democratic Republican Green Independence Libertarian No party affiliation Another party Please specify Introduce Yourself*If you’re chosen to participate, we’ll share what you write below with your conversation partner a few days before you meet. Write a few details that give a sense of who you are, where you're from, the big life events that shaped you (e.g. the birth of children, or losing a loved one), and any issues that are especially important to you. While One Small Step pairs strangers across the political divides, it's also about recognizing our shared humanity. We've found that the best interview partners often share a passion or life experiences. The following questions will help us in the pairing process.Do any of these describe you?Please select as many as you like. Grandparent Parent Political Veteran / From military family Active in my community Outdoorsy / Nature lover Outgoing Animal lover Religious / Spiritual Shy Tech-savvy Creative Have you experienced any of these life events recently?Please select as many as you like. Became a parent Became a grandparent Lost a loved one Moved to a new community Started a new job Lost a job Health or health of a loved one impacted by COVID-19 Got married Got divorced / Had a breakup Fought with family or friends over politics Another major event Please describe List up to three (3) interests or passions in your life (hobbies, sports teams, activities, etc.) Providing StoryCorps with the demographic information on this page is optional. Having more information about you will help us match you with an interview partner, so we encourage you to provide as much as makes you comfortable.AgeGender Female / Woman Male / Man Another gender identity Please specify Race / Ethnicity American Indian or Alaska Native Asian Black or African American Hispanic or Latino/a/x Native Hawaiian or Pacific Islander White/Caucasian Not listed above Please specify Religious affiliation Buddhist Christian Hindu Jewish Muslim Secular/Atheist/Agnostic Unitarian Universalist Not listed above Please specify
