Focus Group Survey Focus Group Application All information collected is for survey purposes only. Selection as a focus group member is not dependent on race, gender, nationality, or religious affiliation. OK Question Title * 1. Contact Information: Name Address Address 2 City/Town State/Province -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code Country Email Address Phone Number OK Question Title * 2. Gender: Male Female OK Question Title * 3. Age: 18-24 25-34 35-44 45-54 55-64 65+ OK Question Title * 4. Race: 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 OK Question Title * 5. Political Affiliation (Democrat, Republican, etc.): Registered Democrat Registered Republican Registered Independent Registered Other, i.e. Green Party, Libertarian, etc. None OK Question Title * 6. Marital Status: Single Married Divorced OK Question Title * 7. Children? Yes No OK Question Title * 8. Your highest level of education: G.E.D High school diploma College Bachelors Degree Masters Degree Doctoral Degree Law Degree Medical Degree (Physician, etc.) OK Question Title * 9. Ever served in the armed forces of the U.S.?: Yes No OK Question Title * 10. Are you employed Yes No OK Question Title * 11. Are you self employed? Yes No OK Question Title * 12. Current Employer details. If unemployed type "none." If retired, please list your last job. Employer Name Employer City and State Your job description/title OK Question Title * 13. How long have you been at your current job? Unemployed 1 month - 5 years 6 - 10 years 11- 15 years 15+ years Retired OK Question Title * 14. Have you ever worked in the medical profession as a tech, a clinical aid, a nurse, a doctor, or as any other medical care provider? If yes, please state occupation. If no, just write, "no." OK Question Title * 15. Have you ever worked for University Hospitals? Yes No OK Question Title * 16. Do you have a family member(s) or a friend(s) that currently work for University Hospitals? Yes No OK Question Title * 17. Do you have family that worked for University Hospitals in the past? Yes No OK Question Title * 18. How do you rate the quality of University Hospital's medical care? Very high quality High quality Neither high nor low quality Low quality Very low quality OK Question Title * 19. Have you ever been a supervisor? Yes No OK Question Title * 20. What is the maximum number of people you've supervised? 0 - I've never been a supervisor 1-5 6-10 11-15 16-20 20+ OK Question Title * 21. What is your income per year? Under $15,000 Between $15,000 and $29,999 Between $30,000 and $49,999 Between $50,000 and $74,999 Between $75,000 and $99,999 Between $100,000 and $150,000 Over $150,000 OK Question Title * 22. Do you own your own vehicle? Yes No OK Question Title * 23. Make and model of your vehicle: OK Question Title * 24. Do you own your own home? Yes No OK Question Title * 25. Have you ever held a leadership position in a church, school, charitable organization, home owner's association, etc.? Yes No OK Question Title * 26. Have you ever served on a jury as the foreperson? Yes No, but I have served on a jury before I have never served on a jury OK Question Title * 27. If you have ever served on a jury before, please describe the kind of case or cases you have heard: OK Question Title * 28. Have you ever been a party to a lawsuit other than divorce? Yes No OK Question Title * 29. If you have been in a lawsuit before, please describe the kind of lawsuit: OK Question Title * 30. Are you suspicious of people who bring lawsuits? Yes No OK Question Title * 31. Do you think our system of justice is broken? Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree OK Question Title * 32. Do you feel that the majority of lawsuits are frivolous? Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree OK Question Title * 33. Do you feel that lawsuits can bring about positive change? Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree OK Question Title * 34. Do you feel that lawsuits cause us to pay more for goods or services? Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree OK Question Title * 35. Do you feel society has a responsibility to make life better for the less advantaged? Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree OK Question Title * 36. Do you feel there should be limits on the amount of money a person can be awarded in a lawsuit for bodily injuries or death? Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree OK Question Title * 37. If you have ever participated in one or more focus groups, please describe: OK Question Title * 38. Name of the last book or magazine you've read: OK Question Title * 39. Favorite kind of movie: thriller, romantic comedy, action-adventure, etc.? OK Question Title * 40. What hobbies do you enjoy? OK DONE