Houston Studies- Care Circles- November/December 2017

Demographic Section

Plaza Research Houston is conducting a Care Circle discussion with consumers 65 years and older and their Caregivers. The first, in-home phase, takes place between Tuesday, November 28th, 2017 and Friday, December 1st, 2017 at various times of the day. The second phase takes place via phone between Monday, December 11th, 2017 and Monday, December 18th, 2017. Phase 1 is 90-minutes per person, and the incentive is $200 each. Phase 2 is 1-hour and the incentive is $100 each.

Please answer the questions below. If you look like a match, we will contact you by telephone.

**Due to the large response to our surveys, we are only able to contact those that look like a match. Please continue to answer future studies, as you may be a match to those.

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* 1. Please provide us with the following information. We will be contacting you by telephone if you seem like a match.

Name:

ZIP:

Email Address:

Phone Number:

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* 2. Alternate Contact number

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* 3. What is your Employment Status?

Please list the occupation, company and industry for all employed members of your household

Houston Studies- Care Circles- November/December 2017

Demographic Section

Question Title

* 1. Please provide us with the following information. We will be contacting you by telephone if you seem like a match.

Question Title

* 2. Alternate Contact number

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* 3. What is your Employment Status?

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* 4. Are you male or female?

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* 5. What is your age?