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.

Question Title

* 1. Name

Question Title

* 2. Phone

Question Title

* 3. Email

Question Title

* 4. The Tennessee county I live in is:

Question Title

* 5. The area I live in is:

Urban

Suburban

Rural

Question Title

* 6. My annual household income is:

$0 - $25,000

$25,000 - $50,000

$50,000 - $75,000

$75,000 - $100,000

$100,000+

Question Title

* 7. I identify my gender as:

Female

Male

Non-binary/third gender

Prefer not to answer

Prefer to self-describe:

Question Title

* 8. My age is:

Under 18

18-24

25-34

35-44

45-54

55-64

65+

Question Title

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

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)

Focus Group Screener

Question Title

* 1. Name

Question Title

* 2. Phone

Question Title

* 3. Email

Question Title

* 4. The Tennessee county I live in is:

Question Title

* 5. The area I live in is:

Question Title

* 6. My annual household income is:

Question Title

* 7. I identify my gender as:

Question Title

* 8. My age is:

Question Title

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

Question Title

* 10. I am a: