ChilliDB for Not For Profit - ChilliDB

Qualitative Research Panel

Web Enquiry Form

Personal information you provide is protected by the Privacy Act 1988. All information you provide is confidential and used for research purposes only. All information collected will be stored under secure password-protected conditions at the Social Research Centre and destroyed after five years (unless requested otherwise).

Please note: at this stage we are only accepting those who are 18 or over.

Confirm Deletion

1.Please select the title you identify with:

Mr
Ms
Miss
Mrs
Dr
Mx

2.Your first name:

3.Your last name:

4.Your date of birth:

5.Do you identify as Aboriginal or Torres Strait Islander?

6.Please complete – ‘I identify my gender as...'

Female
Transgender Female
Male
Transgender Male
Gender fluid / Non binary identifying

7.Do you identify as LGBITQA+?

Yes
No
Maybe

8.How do you identify?

Lesbian
Gay
Bisexual
Intersex
Transgender
Queer/Questioning
Asexual

9.Your residential postcode

10.The state you reside in:

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

11.Your primary contact number:

12.Secondary contact number:

13.Your email address: please note our research invitations are sent to your email address.

14.Marital status:

Single
Married
In a Relationship
Divorced
Widowed
Separated
De facto

15.Do you have any children?

16.Please list the year/s of birth of your child/ern.

17.Which of these categories contains the combined income of your household, before tax and other deductions are taken out during the last financial year?

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

18.Your household type:

Person living alone
Couple only
Couple with dependent child/ren
Couple with non-dependent child/ren
Couple with dependent and non-dependent child/ren
Single parent with dependent child/ren
Single parent with non-dependent child/ren
Single parent with dependent and non-dependent child/ren
Non-related adults sharing a house/apartment/unit/flat
Related adults sharing a house/apartment/unit/flat

19.What is your country of birth?

20.Is English the main language you speak at home?

Yes
No

21.Do you speak a language other than English at home?

Yes
No

22.What language/s do you speak at home?

23.Please identify your residency status - 'I am ...

an Australian citizen
a Permanent resident
on a Student visa
on a Working or skilled visa

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

25.Your main employment status currently is...

Full-time
Part-time
Casual
Fixed term
Student
Home duties
Retired
Unemployed
Not Working/Not looking for work

26.What industry do you work in?

27.Approximately how many employees work for your employer?

Between 1-20 employees
Between 21-60 employees
Between 61-100 employees
Over 100 employees
Don&
39;t know / Unsure / Not applicable
Don&
Don&amp;
Don't know / Unsure / Not applicable

28.What is the highest level of education you have completed?

Senior Secondary Certificate of Education
Certificate I
Certificate II
Certificate III
Certificate IV
Diploma
Advanced Diploma, Associate Degree
Bachelors Degree
Bachelor Honours Degree, Graduate Certificate, Graduate Diploma
Masters Degree
Doctoral Degree
Bachelor Degree
Bachelor Honours Degree
Graduate Certificate
Graduate Diploma

29.Which of the following education institutions did you complete your highest level of education at?

Secondary school (public)
Secondary school (private)
Technical or further educational institution (including TAFE Colleges)
University or other higher educational institution
Other tertiary educational institution

30.What was the field of study that your highest level of education was completed in?
(e.g. engineering, plumbing, school certificate, VCE, VCAL)

31.How did you find out about us?

Search engine (i.e. Google)
Social media
Heard from a friend

32.Contact Type

33.Organisation Name

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