National Telephone study - Medical Issue

1. Default Section

Plaza Research Chicago is conducting a Nationwide Telephone study with Males & Females age 20-59 yrs regarding health management.

The study would take place the week of July 26-July 30 and the telephone interviews would be at various times throughout the day. If you qualify and participate in the study you would receive $75 for 45 minutes of your time.

You would be asked to review some materials through a secure internet website so you would need access to a computer at the time of the telephone interview. We would also forward you a link to a computer software program known as Microsoft SilverLight, which you would need to download to your computer to view the materials for the interview.

If you are willing to do this please answer the questions below to see if you meet the specifications we are looking for.

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* 1. Contact Information

Name:

City/Town:

State:

Email Address:

Phone Number:

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* 2. Which best describes your current employment situation?

Work outside the home full time

Work outside the home part time

Not currently working

Self employed

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* 3. Which best describes the current employment situation of your spouse?

Works outside the home on a full time basis

Works outside the home on a part time basis

Self employed

Not Currently employed

Does not apply

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* 4. Your occupation?

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* 5. Spouse's Occupation

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* 6. Over the course of the past 12 months, how many times would you ay that you have visited a doctor for any reason?

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* 7. How would you characterize your overall health?

Extremely healthy

Very healthy

Somewhat healthy

Not very healthy

Extremely unhealthy

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* 8. Has a physician ever diagnosed and treated you for any of the following conditions?

High blood pressure

Asthma

COPD

Depression

Diabetes

Chronic allergies

Heart disease

Arthritis

None of the above

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* 9. Do you have any children living at home with you who are under 18 years of age?

Yes

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* 10. Age

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* 11. Education

Some high school

High school graduate

Some college

College degree

Post graduate

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* 12. Household income

Under $20,000

$20,000-39,999

$40,000-59,999

$60,000-79,999

Over $79,000

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* 13. Ethnic background

Caucasian

African American

Hispanic

Asian

Multi-racial

Other (please specify)

Thank you for your time. If you meet the specifications we are looking for someone from Plaza Research Chicago will contact you to ask you some additional questions and see if you can qualify for this study.