Demographics

The Community Collaborative is conducting focus groups regarding health related matters including health needs, access to services, and barriers to care. This information will help us organize the focus groups. 

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* 1. What is your first name?

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* 2. What town do you live in?

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* 3. Please provide the zip code where you live.

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* 4. What is your gender?

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* 5. What is your educational level?

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* 6. Do you work in the healthcare field?

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* 7. What age category do you belong? 

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* 8. Please describe your health insurance coverage

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* 9. When are you available to participate in a focus group? (Check all that apply)

  Wednesday, May 8th Wednesday, May 15th Thursday, May 9th Thursday, May 16th Saturday, May 11th Saturday, May 18th
Morning
Afternoon
Evening

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* 10. What is the best way to contact you?

0 of 10 answered
 

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