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$150 Online Study
*
1.
Contact Info
(Required.)
Name
Phone
E-Mail
Gender
City
State
Age
*
2.
Have you or has any member of your household or immediate family ever been employed in any of the following professions?
(Required.)
Physician
Registered Nurse / Physician Assistant
Pharmacist
Pharmaceutical Company
Any other health care setting
None of the above
*
3.
Which of the following best reflects how you would identify your ethnicity/culture?
(Required.)
Black or African American
White or Caucasian
Asian or Pacific Islander
Native American or American Indian
Hispanic or Latino
Other (please specify)
*
4.
With which of the following medical conditions have you been diagnosed with?
**CAN BE NONE OF THESE **
(Required.)
Diabetes
Depression/ Anxiety
High Cholesterol
High Blood Pressure
Parkison’s Disease
Hepatitis C
HIV
A blood disorder, such as Hemophilia or Von Willebrand Disease
None of these
*
5.
Because this study is focused on sexual health, you will be asked some potentially sensitive personal questions about your sexual preference and behaviors as part of our conversation right now and during your individual interview. As a reminder, your responses will be kept completely confidential, and will be separated from your identity. Do you feel comfortable honestly answering these types of questions in this context?
(Required.)
Yes
No