Group Discussion on Health Insurance- pays $150! (PV012926) Survey

We want to hear about your experience with healthcare. If you qualify, we will invite you to a 90-minute group discussion on Thursday, January 29th at a facility in Irvine, for which you will receive $150. This is not a sales or recruitment group, and there will be no sales follow-up as a result of participation.

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1. Please enter your first and last names. (Required.)

First name:

Last name:

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2. Please enter your phone number as 10 digits without any other characters. (Ex: 1234567890) (Required.)

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3. Please enter an e-mail where you can be reached. (Required.)

*By providing my email and/or cell phone number I agree to receive communications via email, phone, and text to that number and email address from Atkins Research Global, Inc. with updates and opportunities. Standard message & data rates may apply. Text STOP to opt-out at any time. Text HELP for more info. Recurring messages. https://www.atkinsresearch.com/privacy-policy/

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4. May we text you at the number above? (Required.)

Yes

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5. What is your gender identity? (Required.)

Male

Female

I prefer to describe myself as (please specify)

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6. What county and state do you live in? (Required.)

State:

County:

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7. Do you currently have health insurance? (Required.)

Yes

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8. Which of the following best describes the type of insurance that you have, if any? If you have more than one insurance, select your PRIMARY Insurance (the insurance you use the most). (Required.)

Covered California

Medi-Cal

Medicare

Insurance through an employer

Insurance purchased on your own

Don’t know

None

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9. What is the name of your PRIMARY insurance company? Your primary insurance is the one you use the most. Please look at your insurance card to verify type of plan and carrier. (Required.)

CalOptima

Uninsured

Other (please specify)

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10. Over the last few years have you ever been enrolled in a Medi-Cal plan through CalOptima Health? (Required.)

Yes

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11. Which of the following best describes your ethnic background? Select all that apply. (Required.)

White/Caucasian

Black African-American

Asian

Hispanic/Latino

Not Listed (please specify)

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12. Where were you born? (Required.)

I was born in the United States.

I was born in:

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13. Where was your mother born? (Required.)

She was born in the United States.

She was born in:

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14. Where was your father born? (Required.)

He was born in the United States.

He was born in:

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15. What language do you prefer speaking? (Required.)

English

Spanish

Vietnamese

Other language

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16. At home, would you say that you … (Required.)

Speak English all the time

Speak English most of the time

Speak English some of the time, but I prefer another language

Don’t Know

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17. What language do you speak with your family and friends? (Required.)

English always

English mostly

English some of the time, but I prefer another language

Don’t know

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18. How well would you say you read in English? (Required.)

Very Well

Well

So-so

Not well

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19. What is your age? (Required.)

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20. What is your date of birth? (Required.)

MM/DD./YYYY

Date

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21. What is your highest level of education? (Required.)

Less than high school

High school graduate or GED

Some college or vocational school, press

Bachelor’s degree or higher

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22. If you qualify, we will invite you to a 90-minute group discussion on Thursday, January 29th at a facility in Irvine, for which you will receive $150.

The group will begin at 5:00 PM Pacific Time. We will need you to arrive 15 minutes before the group to check in. Will you be able to join us? (Required.)

Yes

Unsure

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23. Please enter your street address. (Required.)

Thank you for your time. If you qualify, a staff member will contact you to follow up.

Group Discussion on Health Insurance- pays $150! (PV012926)

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* 1. Please enter your first and last names. (Required.)

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* 2. Please enter your phone number as 10 digits without any other characters. (Ex: 1234567890) (Required.)

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* 3. Please enter an e-mail where you can be reached. (Required.)

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* 4. May we text you at the number above? (Required.)

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* 5. What is your gender identity? (Required.)

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* 6. What county and state do you live in? (Required.)

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* 7. Do you currently have health insurance? (Required.)

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* 8. Which of the following best describes the type of insurance that you have, if any? If you have more than one insurance, select your PRIMARY Insurance (the insurance you use the most). (Required.)

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* 9. What is the name of your PRIMARY insurance company? Your primary insurance is the one you use the most. Please look at your insurance card to verify type of plan and carrier. (Required.)

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* 10. Over the last few years have you ever been enrolled in a Medi-Cal plan through CalOptima Health? (Required.)

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* 11. Which of the following best describes your ethnic background? Select all that apply. (Required.)

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* 12. Where were you born? (Required.)

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* 13. Where was your mother born? (Required.)

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* 14. Where was your father born? (Required.)

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* 15. What language do you prefer speaking? (Required.)

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* 16. At home, would you say that you … (Required.)

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* 17. What language do you speak with your family and friends? (Required.)

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* 18. How well would you say you read in English? (Required.)

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* 19. What is your age? (Required.)

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* 20. What is your date of birth? (Required.)

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* 21. What is your highest level of education? (Required.)

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* 23. Please enter your street address. (Required.)

1. Please enter your first and last names. (Required.)

2. Please enter your phone number as 10 digits without any other characters. (Ex: 1234567890) (Required.)

3. Please enter an e-mail where you can be reached. (Required.)

4. May we text you at the number above? (Required.)

5. What is your gender identity? (Required.)

6. What county and state do you live in? (Required.)

7. Do you currently have health insurance? (Required.)

8. Which of the following best describes the type of insurance that you have, if any? If you have more than one insurance, select your PRIMARY Insurance (the insurance you use the most). (Required.)

9. What is the name of your PRIMARY insurance company? Your primary insurance is the one you use the most. Please look at your insurance card to verify type of plan and carrier. (Required.)

10. Over the last few years have you ever been enrolled in a Medi-Cal plan through CalOptima Health? (Required.)

11. Which of the following best describes your ethnic background? Select all that apply. (Required.)

12. Where were you born? (Required.)

13. Where was your mother born? (Required.)

14. Where was your father born? (Required.)

15. What language do you prefer speaking? (Required.)

16. At home, would you say that you … (Required.)

17. What language do you speak with your family and friends? (Required.)

18. How well would you say you read in English? (Required.)

19. What is your age? (Required.)

20. What is your date of birth? (Required.)

21. What is your highest level of education? (Required.)

23. Please enter your street address. (Required.)