Pre-screener to be considered

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* 1. Contact Information

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* 2. Which county do you reside in?

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* 3. Do you, or does any member of your family, currently or formerly work for…

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* 4. What is your age?

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* 5. Are you … ?

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* 6. Where were you born?

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* 7. How long have you lived in the US?

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* 8. Which of the following best describes your ethnic background?

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* 9. What languages were spoken in the household in which you grew up?

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* 10. What is your preferred language when interacting with healthcare providers?

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* 11. The questions you will see next ask about your health insurance status, the name of your provider (if you are insured) and how you obtained coverage (if applicable). The purpose of these questions is to determine if you are a good fit for our research study. Any information obtained in this screening process is protected digitally and will only be shared with the research team and its client. If you qualify to participate in our research study, we will request you sign a formal confidentiality and HIPAA release form, fulfilling HIPAA privacy rules as well as the research team’s privacy policy. Personal information obtained under these forms is for the scope of the research project and nothing else. All information obtained from the screening process for this research is removed after 90 days but may be removed earlier upon your written request. Before proceeding with this questionnaire, please indicate “Yes” to indicate you understand we will be asking about this protected information. If you are not interested in applying, please indicate “No”.

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* 12. Which of the following best describes the type of health insurance you have?

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