Houston Study - Diabetes Care March 2017

1. Introduction Section

Plaza Research Houston is conducting a discussion with Adults with Diabetes and Parents of Children with Diabetes regarding Diabetes Care. The discussion will take place onTuesday, March 14th thru Wednesday, March 16th, 2017, time varies throughout the day. If you qualify and participate, you will $400 for 5-hours of your time.

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/Postal Code:

Email Address:

Phone Number:

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* 2. Alternate Contact number

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* 3. What is your age? Whole number, no ranges or words

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* 4. What is your gender?

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* 5. Which one best describes you?

I have Diabetes

I'm a parent with a child(re) with Diabetes

None of the above