FIRST NAME:

LAST NAME:

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EMAIL:

ZIP:

 YOUR AGE:

Select your age group! 18 - 21 22 - 27 28 - 35 35 - 44 45 - 50 51 - 60 60+

YOUR FAVORITE COLOR:

Select your favorite color! tye dye patterns pastels black & white red green blue purple no preference

YOUR FAVORITE TYPE OF MUSIC:

Select your favorite music! blues blue grass classical classic rock country dixie land easy listening heavy metal hip hop jazz new age pop rap western

YOUR FAVORITE RADIO STATION:

YOUR FAVORITE MOVIES / TV:

What sort of movies or TV do you enjoy MOST? drama suspense romance thrillers comedy cartoons news documentary foreign no preference

NAME THE LAST MOVIE YOU SAW:

NAME YOUR FAVORITE MAGAZINE:

WHAT DO YOU THINK OF DOCTAJ.COM:

Please rate DoctaJ.com! very helpful somewhat helpful not helpful too time consuming! could not do without it!

PROVIDE 3 SHORT SUGGESTIONS 
FOR IMPROVING DOCTAJ.COM: 

1.

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3.

WHAT CAMPUS DID YOU ATTEND:

Where did you take the class? Newport Warwick Providence Lincoln

SELECT YOUR SECTION:

What is or was your section#? 999 Guest 001 Warwick 002 Warwick 003 Warwick 581 Newport 582 Newport 583 Newport 584 Newport 306 Providence 307 Providence

SEMESTER:

When did you take the class? Spring Summer 1 Fall

MAJOR:

What is your major? Nursing OTA PTA TMSG other heatlh program Liberal Arts undecided

ASSISTANCE:

Will you help us? YES NO

SKILLS:

Select a skill that applies! clerical etc. design editing illustration photography programming video web stuff

THANKS A BUNCH... 
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