216768 (May dates) Question Title * 1. Contact Information (Required.) First Name Last Name Address Address 2 City/Town State/Province -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code Country Email Address Phone Number Question Title * 2. What is your gender? Female Male Other (specify) Question Title * 3. What is your date of birth? (Required.) Date Date Question Title * 4. I am: Single Married Divorced Widowed Question Title * 5. I live: Alone With others (i.e. partner, spouse, family or friends) Question Title * 6. What is your ethnicity? (please select all that apply) (Required.) White / Caucasian Black or African American Hispanic or Latino Asian or Asian American American Indian or Alaska Native Native Hawaiian or other Pacific Islander Prefer not to answer Other (please specify) Question Title * 7. Are you employed? (Required.) Yes No Retired Question Title * 8. Please list your current position. Question Title * 9. If unemployed or retired, please list your most recent position. Question Title * 10. Do you now, or have you ever, worked for Miami Valley Hospital? (Required.) Yes No If yes, please state the time frame of your employment at Miami Valley Hospital and your title. Question Title * 11. Do you now, or have you ever, worked for Cardiothoracic Surgery Associates? (Required.) Yes No If yes, please state the time frame of your employment at Cardiothoracic Surgery Associates and your title. Question Title * 12. Do you now, or have you ever, worked for Premier Health Specialists, Inc.? (Required.) Yes No If yes, please state the time frame of your employment at Premier Health Specialists, Inc. and your title. Question Title * 13. Do you now, or have you ever, worked for Dr. Syed Zaman? (Required.) Yes No If yes, please state the time frame of your employment with Dr. Syed Zaman and your title. Question Title * 14. Are you now, or have you ever been, a patient of Dr. Syed Zaman? (Required.) Yes No If yes, please state the time frame of your treatment with Dr. Syed Zaman. Question Title * 15. What is the highest level of education you have completed? (Required.) Graduated from high school or GED Graduated from college Some college or vocational training Question Title * 16. Do you have children? Yes No Question Title * 17. Are you a registered voter? (Required.) Yes No Question Title * 18. Political party affiliation: (Required.) Registered Democrat Registered Republican Registered Independent Undecided Question Title * 19. What is the last presidential election you voted in? (Required.) 2020 2016 Before 2016 Question Title * 20. With regard to jury service, I... (Required.) am eligible for jury service (American citizen with no felony convictions) but have never been contacted have been called to report for jury service, but was not selected for a case have served as a juror on a civil case have served as a juror on a criminal case am not eligible to serve on a jury because of a previous criminal conviction Question Title * 21. Other than a divorce, have you ever been a party to a lawsuit? No, I have never been involved in a lawsuit Yes, I was a Plaintiff in a lawsuit Yes, I was a Defendant in a lawsuit Yes, I have been both a Plaintiff and a Defendant in lawsuits If yes, what kind of case did the dispute involve? Question Title * 22. I have social media accounts on: (Required.) Facebook X (Twitter) Instagram Parler Gab Tik Tok Telegram Truth Social None of the above Question Title * 23. Wheter television or internet, what national news organization are you likely to get your news from? ABC CBS NBC CNN FOX MSNBC NewsNation Other (please specify) Question Title * 24. I have lost friends or family because of political beliefs: (Required.) None A few Some Most All Question Title * 25. What is your favorite movie genre? Comedy Adventure Drama Romantic Horror Thriller/Suspense Romantic Comedy Documentary Question Title * 26. Have you ever donated your time, money or items to charity? Time Money Items None of the above Question Title * 27. If selected to participate in this focus group, my preferred session is: (Required.) Tuesday, May 14, 2024 9:00am-1:00pm Tuesday, May 14, 2024 2:00pm-6:00pm Additional Comments Done
