Houston Studies Late June 2015 Survey

Plaza Research Houston is looking for diabetes patients age 40-64 to commit to a 30 day evaluation of an adherence program. This study will begin Monday, June 22nd, ending Friday, July 24th, 2015. If you qualify and are chosen to participate, you will receive $350 for participating in the 30-day study consisting of online activities, telephone interviews and a 90-minute focus group.

We are also looking for Males 25-35 years old to participate in a discussion on Beer. The study takes place at a Galleria-area hotel on Monday, June 29th, 2015 in the evening. If you qualify and are chosen to participate, you will receive $175 for 3-hours of your time (Plus Dinner).

Please answer the questions below. If you look like a match, we will contact you by telephone.

**Due to the large response to our surveys, we are only able to contact those that look like a match. Please continue to answer future studies, as you may be a match to those.

1.Please provide us with the following information. We will be contacting you by telephone if you seem like a match.(Required.)

Name:

ZIP:

Email Address:

Phone Number:

2.Alternate Contact number

3.What is your Employment Status?(Required.)

Please list the occupation, company and industry for all employed members of your household

4.Generally speaking, is your occupation....

Other (please specify)

5.Please answer the following demographic questions.(Required.)

Age range

Marital Status

Gender

Ethnicity

Education

Income

Demographic Information

6.What is your exact age?

8.When was the last time, if ever, you participated in a focus group discussion or individual interview and what was the topic?(Required.)

9.Do you want to answer question about Diabetes?

Yes

No

Houston Studies Late June 2015

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