Houston Studies - Dialysis October 2016

1. Deographic Section

Plaza Research Houston, a market research facility in the Galleria area, is looking for dialysis Patients & Nurses to participate in a individual interview. This study will be held on Thursday, October 20th through Friday, October 21st, 2016. If you qualify and are chosen to participate, you will receive $150 for participating in the 75 minute focus group.

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.

REFERRAL INCENTIVE OF $75 FOR ANY QUALIFIED NEPHROLOGISTS & $50 FOR ANY QUALIFIED NURSES THAT PARTICIPATE ON YOUR BEHALF. Please forward this survey to anyone you know that may qualify.

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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 age?

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* 4. Which of the following categories best describes your employment status?

Employed, working full-time

Employed, working part-time

Not employed, looking for work

Not employed, NOT looking for work

Retired

Disabled, not able to work

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* 5. What is your occupation?

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* 6. What is the name and phone number or email of the person who referred you?

Name

Phone Number

Email Address