MOMSI Participant Recruitment Form

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Thank you for your interest in helping O'Fallon Historical Museum measure social impact. If selected to participate, you will visit the museum with a friend or family member 3 different times. You will then complete a 30-minute survey to share how your experiences at the museum impacted various outcomes. If you do not have internet access, we may be able to provide a computer and a space for you to take the survey or recommend options for access.

The O'Fallon Historical Museum may use quotes or other responses from the social impact survey in reports and publications. Any personal information will be kept confidential.

Your participation in the study is completely voluntary. You may withdraw at any time or refuse to participate entirely. There will be no penalty if such actions are taken except that you will forfeit your opportunity to attend the museum for free.

As part of your participation, you and a guest will be given free admission to the O'Fallon Historical Museum. Additionally, you will have the option of entering yourself into an opportunity drawing if you complete the social impact survey, which will be emailed to you after completing up to 3 visits.

Email *

I am 18 years of age or older. *

Yes

I have read and agree to the above and desire to participate in the social impact study at O'Fallon Historical Museum.

Yes

In a normal year, how often do you visit O'Fallon Historical Museum? *

I have never attended this museum

I have attended this museum 1-2 times in a regular year

I attend this museum regularly (3+ times a year)

Are you a member of this museum? *

Yes

The following information will only be used for the purpose of this study. We will not share or distribute any of the following information.

Please type in your first and last name, email address, and city, state, and zip code.

What is your gender?

Male

Female

Prefer not to say

Other:

Clear selection

With which racial or ethnic group(s) do you identify? (Select all that apply).

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Native Hawaiian or Pacific Islander

White or Caucasian

Prefer not to say

Other:

What is your age?

18-24

25-34

35-44

45-54

55-64

65-74

75 or older

Clear selection

What is your annual household income?

I prefer not to say

Below $10,000

$10,000-$19,999

$20,000-$29,999

$30,000-$39,999

$40,000-$49,999

$50,000-$59,999

$60,000-$69,999

$70,000-$79,999

$80,000-$89,999

$90,000-$99,999

$100,000-$109,999

$110,000-$119,999

$120,000-$129,999

$130,000-$139,999

$140,000-$149,999

$150,000 or higher

Clear selection

Send me a copy of my responses.

Submit

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