* 1. Name (this will be kept private unless you are contacted by a Reuters reporter and agree to have your name published)

* 2. Email Address

* 3. Telephone number

* 4. How old are you?

* 5. Do you currently have health insurance, or not?

* 6. What state exchange website did you enter?

* 7. Can you sign on to your exchange?

* 8. Can you check whether you are eligible for a subsidy or Medicaid?

* 9. Can you see information on insurance plans?

* 10. Can you check if your doctor is in an insurance plan’s network?

* 11. Any problems moving from page to page on the site?

* 12. If problems moving from page to page on the site, please describe

* 13. Please describe any other issues or comments

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