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This survey will collect data regarding the use of PBJ(c) in the state of Maryland. All responses and data collected will remain anonymous and confidential. It will not be released with any personal identifying information, only aggregate data will be released to report on the overall PBJ(c) usage in the state. By filling out the information below, you and your client provide us consent to collect and analyze the data at a later point in time. If you do not wish to participate, you can close the survey.
Name of Client
Case Number
What is the racial background of your client?
White, Non-Hispanic
Hispanic
Black or African American
Asian
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
South Asian
Two or more races
Some other race
With which gender does your client identify?
Male
Female
Non-binary / third gender
Prefer not to say
What is your client's occupation?
Is your client a citizen of the United States? That is, were they born in the United States, born in a U.S. territory, born of U.S. citizen parent(s), or become a citizen of the U.S. through naturalization?
Yes, a U.S. Citizen
No, not a U.S. Citizen
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