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NiandCompany LLC Onboarding Survey
the first step is vital
First name
Last name
Name Pronunciation
Preferred Name
Birthday
Month
Day
Year
Email
Phone
SEX
MALE
FEMALE
Non-binary
GENDER IDENITIFY
Gender Fluid
Gender Queer
Intersex / DSD
Do not idenitfy with labels
Pronouns
*
MARITAL STATUS
Single
Married
Widowed
Seperated
Divorced
RACE(S)
SPOKEN LANGUAGE(S)
ETHNICITY
Employment Status
Employ
Unemployed
Employed - Part Time
Employed - Full Time
Disabled
Retired
Highest Level of Education Completed
No Education
Grade School
Middle School
High School or Equivalent
Trade School
Associate's Degree
Bachelor's Degree
Some College No Degree
Master's Degree
Doctoral Degree
Professional Degree and Certification - Med Tech, Nurse's Aide, MD, RN, LSW
PhD
Pregnancy Status
Not Pregnant
Postpartum
Pregnant
Number of Children In Household
Number of People In Household
Primary Insurance Company
Anthem Blue Cross Blue Shield
Contra Costa Health Plan
Health Net
Independent Living Systems (Kaiser)
Molina Healthcare California
San Francisco Health Plan
Option 7
Secondary Insurance Company
Medicaid Status
Enrolled
Not Enrolled
Application Pending
Unknown
Primary CIN
Secondary CIN
ADDRESS
COUNTRY
STATE
CITY
ZIP CODE
TIMEZONE
Hawaii Standard Time GMT-10:00
Alaska Standard Time GMT-9:00
Pacific Standard Time GMT-8:00
Phoenix Standard Time GMT-7:00
Mountain Standard Time GMT-7:00
Central Standard Time GMT-6:00
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