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T.I.E. Survey
1.
What is your name?
*
2.
What is your email address?
(Required.)
*
3.
What is your cell phone number?
(Required.)
*
4.
Do you currently have a job?
(Required.)
Yes
No
*
5.
Where are you working?
(Required.)
*
6.
What is the address where you currently work?
(Required.)
*
7.
How many hours do you work per week?
(Required.)
Less than 20 hours per week
20 to 39 hours per week
40 hours or more per week
Not employed, looking for work
Disabled, not able to work
Retired
Other (please specify)
*
8.
What is your average weekly income?
(Required.)
Less than $300 per week
$300 to $450 per week
$455 to $650 per week
$655 to $850 per week
$855 to $1050 per week
$1055 per week or more
Other (please specify)
*
9.
What type of health insurance do you have?
(Required.)
Private Insurance
Medicaid
No Insurance
Other
Other (please specify)
*
10.
If you have Medicaid, which is your Medicaid Provider?
(Required.)
Aetna
AmeriHealth Caritas
Healthy Blue Louisiana
Louisiana Healthcare Connections
United Healthcare
Other (please specify)
*
11.
How did you get to court?
(Required.)
Drove my car
Took the bus
Rode my bike
Caught a ride
Other (please specify)
Current Progress,
0 of 11 answered