Health Opinions Pre-screener to be considered Question Title * 1. Please provide your contact information Name Social media link City/Town State/Province Country Email Address Phone Number OK Question Title * 2. Are you interested and available to participate in an online, video discussion group (conducted via Zoom) at any of the following times? We will be conducting groups at variety of times. Please select ALL of the times below that you are available to participate. Wednesday Sept 15: 12-1 pm EST Wednesday Sept 15: 2-3 pm EST Wednesday Sept 15: 5-6 pm EST Thursday, Sept 16: 12-1 pm EST Thursday, Sept 16: 2-3 pm EST Thursday, Sept 16: 5-6 pm EST Tuesday, Sept 21: 12-1 pm EST Tuesday, Sept 21: 2-3 pm EST Tuesday, Sept 21: 5-6 pm EST Wednesday, Sept 22: 12-1 pm EST I am not available to participate at any of the times listed above OK Question Title * 3. When were you born? Please let us know in mm-yyyy OK Question Title * 4. Identify yourself as... Male Female Other (please specify) OK Question Title * 5. What is your family situation? Single without children Single with children Cohabiting/ married without children Cohabiting/ married with children Living with (grand)parent(s)/ family OK Question Title * 6. Are you professionally active in any of the following sectors? Please select all that apply. Transport (e.g. haulage, storage & courier, aviation, expedition) Market research Advertising / marketing Production of Consumer Packed Goods I am currently not professionally active (e.g. student, unemployed, physically challenged, househusband/housewife, retired) Media / journalism / radio / TV Financial and insurance sector Catering and restaurant services Telecom, ICT, software, hardware Health care & social services Distribution (retail and wholesale) Recreation & other personal services (e.g. tourism) Hotel services Construction Manufacturing various products / industry (e.g. chemistry, pharmaceuticals, machine construction, nutrition, electricity…) Government Consulting, research and development Other (please specify) None of the above OK Question Title * 7. What state do you live in? Maine New Hampshire Vermont Massachusetts Rhode Island Connecticut New York Pennsylvania New Jersey Delaware Maryland Washington D.C. Wisconsin Michigan Illinois Indiana Ohio North Dakota South Dakota Nebraska Kansas Minnesota Iowa Missouri Virginia West Virginia North Carolina South Carolina Georgia Florida Kentucky Tennessee Mississippi Alabama Oklahoma Texas Arkansas Louisiana Idaho Montana Wyoming Nevada Utah Colorado Arizona New Mexico Alaska Washington Oregon California Hawaii None of the above OK Question Title * 8. Which, if any, of the products listed below have you purchased and consumed in the past 3 months? Please select all that apply. Vitamins and/or supplements Protein Bars Meal Replacement/ Shakes Bottled Water None of the above OK NEXT
