General Information

Your answers to these questions will determine your eligibility for our focus group. We are seeking a broad cross-section of the general population.

Which category below includes your age? (Age 20 or older is required.)

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* 1. Which category below includes your age? (Age 20 or older is required.)

What is your gender?

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* 2. What is your gender?

What is your racial/ethnic background?

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* 3. What is your racial/ethnic background?

In which county do you reside?

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* 4. In which county do you reside?

Are you registered to vote?

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* 5. Are you registered to vote?

For whom did you vote in the 2012 presidential election?

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* 6. For whom did you vote in the 2012 presidential election?

For whom did you vote in the 2016 presidential election?

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* 7. For whom did you vote in the 2016 presidential election?

What is the highest level of education you completed?

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* 8. What is the highest level of education you completed?

What were your last two employment areas (including current employment)?

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* 9. What were your last two employment areas (including current employment)?

Have you ever filed a personal injury or wrongful death lawsuit?

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* 10. Have you ever filed a personal injury or wrongful death lawsuit?

Do you currently work in a hospital or doctor's office?

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* 11. Do you currently work in a hospital or doctor's office?

What is your full name? (This information is confidential. We will only use it to contact you if you are eligible and to issue your payment if you attend. We will never give or sell this information to anyone else. IF YOU DO NOT PROVIDE THIS INFORMATION, WE HAVE NO WAY TO CONTACT YOU IF YOU QUALIFY.)

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* 12. What is your full name? (This information is confidential. We will only use it to contact you if you are eligible and to issue your payment if you attend. We will never give or sell this information to anyone else. IF YOU DO NOT PROVIDE THIS INFORMATION, WE HAVE NO WAY TO CONTACT YOU IF YOU QUALIFY.)

What is your email address? (This information is confidential. We will only use it to contact you if you are eligible. We will never give or sell this information to anyone else. IF YOU DO NOT PROVIDE THIS INFORMATION, WE HAVE NO WAY TO CONTACT YOU IF YOU QUALIFY.)

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* 13. What is your email address? (This information is confidential. We will only use it to contact you if you are eligible. We will never give or sell this information to anyone else. IF YOU DO NOT PROVIDE THIS INFORMATION, WE HAVE NO WAY TO CONTACT YOU IF YOU QUALIFY.)

Have you participated in a focus group in the last two (2) years?

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* 14. Have you participated in a focus group in the last two (2) years?

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