Houston Study -Adult Diabetes October 2018

Introduction Section

Plaza Research Houston is conducting a discussion with people from ages 21-70 on the topic of Diabetes. The discussion takes place Monday, October 15th, and Tuesday, October 16th,2018, time varies throughout the day and evening. If you qualify, and are chosen to participate, you will receive $125 for 1.5 hours of your time PLUS an additional $50 for mandatory homework.

**Proof may be required in order to participate if chosen**

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.

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

First Name *

Last Name *

City/Town

ZIP/Postal Code: *

Email Address: *

Phone Number: *

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* 2. Alternate Contact number

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* 3. What is your age?

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* 4. What is your date of birth?

Date

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

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* 2. Alternate Contact number

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* 3. What is your age?

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* 4. What is your date of birth?

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* 5. What is your gender?