1 15 19 Question Title * 1. Contact Information Name Address Address 2 City/Town ZIP/Postal Code Email Address Phone Number Question Title * 2. Which category below includes your age? (Age 20 or older is required.) 20-29 30-39 40-49 50-59 60 or older Question Title * 3. In which county do you reside? Cook County DuPage County Will County Lake County Kane County Grundy County McHenry County Other Question Title * 4. What is your gender? Female Male Question Title * 5. Which race/ethnicity best describes you? (Please choose only one.) American Indian or Alaskan Native Asian / Pacific Islander Black or African American Hispanic White / Caucasian Multiple ethnicity / Other (please specify) Question Title * 6. Are you a registered voter? Yes No Unsure / Don’t know Question Title * 7. What is the highest level of school you have completed or the highest degree you have received? Less than high school degree High school degree or equivalent (e.g., GED) Some college but no degree Associate degree Bachelor degree Graduate degree Question Title * 8. Which of the following best describes your current relationship status? Married Widowed Divorced Separated In a domestic partnership or civil union Single, but cohabiting with a significant other Single, never married Question Title * 9. Do you have any children under 18? Yes No Question Title * 10. Which of the following best describes your current occupation? Legal Occupations Education, Training, and Library Occupations Arts, Design, Entertainment, Sports, and Media Occupations Business and Financial Operations Occupations Management Occupations Community and Social Service Occupations Office and Administrative Support Occupations Construction and Extraction Occupations Protective Service Occupations Farming, Fishing, and Forestry Occupations Computer and Mathematical Occupations Food Preparation and Serving Related Occupations Building and Grounds Cleaning and Maintenance Occupations Sales and Related Occupations Healthcare Practitioners and Technical Occupations Personal Care and Service Occupations Healthcare Support Occupations Installation, Maintenance, and Repair Occupations Production Occupations Architecture and Engineering Occupations Life, Physical, and Social Science Occupations Transportation and Materials Moving Occupations Other (please specify) Question Title * 11. What is your approximate average household income? $0-$24,999 $25,000-$49,999 $50,000-$74,999 $75,000-$99,999 $100,000-$124,999 $125,000-$149,999 $150,000-$174,999 $175,000-$199,999 $200,000 and up Question Title * 12. Have you ever filed a personal injury or wrongful death lawsuit? Yes No Question Title * 13. Have you ever participated in a focus group or mock jury? Yes No Question Title * 14. What is your political affiliation? Democrat Republican Independent Other Question Title * 15. Have you ever been employed as a healthcare worker? Yes No Next
