CORE Mirror
Enrollment Date
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Participant Name
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Participant Name
First Name
First Name
Last Name
Last Name
Name Suffix
Jr
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I
II
III
Preferred Name
Email
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Zip code
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Birthdate
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Gender
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Male
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Transgender
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Sexual Orientation
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Asexual
Gay or lesbian
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Straight or heterosexual
Questioning or unsure
Self-describes in another way
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Sexual Orientation Detail
Race/Ethnicity
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American Indian or Alaska Native
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Other
Other
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Preferred Language
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English
American Sign Language
Amharic
Arabic
Chinese—Cantonese
Chinese—Mandarin
Dari
Japanese
Khmer
Korean
Marshallese
Punjabi
Russian
Somali
Spanish
Tigrinya
Ukrainian
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Other (specify Language
Detail)
Prefer not to say
Unknown
Disability
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Yes
No
Prefer not to say
Unknown
Experiencing Homelessness
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Yes
No
Prefer not to say
Unknown
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