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Focus Group Screener

Thank you for your interest in participating in a focus group on decision making for people with disabilities. All focus groups will occur online through a video conference. You must have access to internet and a computer with microphone and camera to participate.

Please fill out the survey below. We will contact you if you qualify. Dates for the focus groups will be scheduled May 2019.

*1.Name(Required.)

*2.Phone(Required.)

*3.Email(Required.)

*4.The Tennessee county I live in is:(Required.)

*5.The area I live in is:(Required.)

Urban

Suburban

Rural

*6.My annual household income is:(Required.)

$0 - $25,000

$25,000 - $50,000

$50,000 - $75,000

$75,000 - $100,000

$100,000+

*7.I identify my gender as:(Required.)

Female

Male

Non-binary/third gender

Prefer not to answer

Prefer to self-describe:

*8.My age is:(Required.)

Under 18

18-24

25-34

35-44

45-54

55-64

65+

*9.My race/ethnicity is: (Check all that apply)(Required.)

White or Caucasian

Black or African American

Hispanic or Latino

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Another race

Prefer not to answer

Other (please specify)

*10.I am a:(Required.)

Current Progress,

0 of 16 answered

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