* 1. Please give your full name.

* 2. What County do you reside in?

* 3. What is your age?

* 4. What is your Occupation?

* 5. Do you currently receive health insurance from an employer or do you purchase health insurance from the open market?

* 6. Do you currently have individual or family health insurance coverage?

* 7. Have you recently received notification that your insurance premiums (both deductible and/or monthly cost) will be higher/lower next year? If so, please describe the change in cost (percentage and dollar amount) in detail.

* 8. Are there any other thoughts you would like to share regarding health care reform?