Incontinence and catheter supplemental survey Question Title * 1. If you were to receive absorbent products at no cost to manage your or your loved one's incontinence, would you be willing to in turn help the organization by participating in collecting shoes to raise money for products for others in need? This would in NO WAY identify you as incontinent, you would simply need to tell the persons you are collecting shoes from that the shoes are going to the 3rd world to help with the microecononomies. They need not know that you are raising money for your incontinence products. Yes No OK Question Title * 2. If you answered no, why not? OK Question Title * 3. If you don't receive products from Medicaid and have to buy your own, what is your average monthly income? (All responses are anonymous and will not be traced back to you. We need this information in order to get an idea on how best to serve our recipients, and how to establish eligibility criteria. Less that 500 per month 500-700 per month 700-900 per month 1000-1200 per month 1300-1500 per month 1500-1700 per month 1700-1900 per month 2000-2200 2250 Other (please specify) OK Question Title * 4. What state or country do you reside in? Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachussetts Michigan Missouri Mississippi Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvainia Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia West Virginia Washington Wisconsin Wyoming Country outside the United States OK Question Title * 5. If you use catheters, do you get what you need from insurance? Do you receive enough to meet your daily needs? Yes I recieve what I need from insurance, and yes I receive enough to meet daily needs I receive some catheters but not enough to cover daily needs, have pay some out of pocket I receive no catheters from insurance and have to pay out of pocket I don't use catheters OK Question Title * 6. If you have an infant or toddler with special needs, does your infant/toddler have a disability that increases the amount of diapers used to an amount that is much more than typical for a child their age? If so, by how much? OK Question Title * 7. what is your gender or the gender of the loved one who is incontinent? Male Female Other/indeterminate OK Question Title * 8. If you or your loved one are incontinent, do you have a disability that causes the incontinence? Yes no OK Question Title * 9. If yes, what is the disability? OK Question Title * 10. Have you heard of premium brands of incontinence products such as ConfIDry 24/7, Abena, Molicare, A+ Wellness, and Northshore care? If not, what do you currently use if you are your loved one are incontinent? NOTE: I am NOT trying to promote any specific brand of adult brief, but am simply gauging the public's awareness of incontinence protection options. OK DONE