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Healthcare Study with Superior Focus H
1.
Please fill out the following so we may contact you.
Name
City/Town
ZIP/Postal Code
Email Address
Phone Number
2.
What state do you currently live in?
3.
Would you say you live in an urban, suburban, or rural area?
Urban
Suburban
Rural
Other (please specify)
4.
Do you currently have health insurance? (we are looking for people who do and do not currently have health insurance)
Yes
No
Other (please specify)
5.
How satisfied would you say you are with your current health insurance situation?
Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
Not sure
6.
ONLY including yourself, your spouse, and your children that you claim on your federal taxes, how many people are in your household? Do NOT include other relatives or roommates that you may also live with unless they are on your tax return.
7.
What is your TOTAL, annual HOUSEHOLD income, before taxes? Only include income from yourself, your spouse, and any children that you claim on your federal taxes; do not include income from anyone who cannot be counted on your household’s taxes such as roommates, other relatives, boyfriends, girlfriends, etc.
8.
What is your age?
9.
What is your current marital status?
Single
Married
Divorced
Widowed
Separated
Other (please specify)
10.
What is your gender?
Male
Female
Other (please specify)
11.
What is the highest grade that you finished in school?
12.
Are you of Hispanic or Latino origin or descent?
Yes
No
Not sure
Other (please specify)
13.
Are you fluent in Spanish?
Yes
No
Not sure
14.
Is Spanish your first language?
Yes
No
Not sure
Other (please specify)
15.
Thinking about the times when you are with your family and friends, would you say that you…?
Speak Spanish more than English
Speak Spanish and English equally
Speak English more than Spanish
Not sure
Other (please specify)