Tell us how your kids are covered! Question Title * 1. Are you a parent? Yes No Other (please specify) Question Title * 2. If you are a parent, how old is your child/children? Check all that apply. 0-5 years-old 6-9 years-old 10-14 years-old 15-19 years-old Other (please specify) Question Title * 3. Did your child/children have health insurance in 2014? Yes, I gave insurance to my child/children through my plan Yes, my child/children had coverage through my spouse/partner/another parent’s plan Yes, my child/children had health insurance through the Children’s Health Insurance Program Yes, my child/children had coverage through Medicaid Yes, my child/children had health insurance through some other way No, my child/children did not have health insurance Other (please specify) Question Title * 4. Why is health insurance important for your family? Question Title * 5. If you were told that Congress could cut a health insurance program that covers your child/children, how would that impact your family? Question Title * 6. If you were told that Congress could cut a health insurance program that covers your friend or relative’s child/children, how do you think that would impact them? Question Title * 7. Can we contact you to learn more about your experience? Yes No Other (please specify) Question Title * 8. Please enter your contact information below. (Required.) Name: * Address: Address 2: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: * Country: Email Address: * Phone Number: Done
