Exit Healthcare survey Question Title * 1. First Name Question Title * 2. Last Name Question Title * 3. E-mail Address Question Title * 4. Phone number to reach you Question Title * 5. Your age Question Title * 6. What is the highest level of education that you have completed? Elementary school Some high school High school diploma Some college College / University graduate Post graduate degree Question Title * 7. What is your current employment status? A full-time employee Working part-time Laid-off / looking for work Not employed and not looking for work Full time student Part time student Retired Question Title * 8. Just for classification purposes:Would you mind telling us which of the following categories best describes your current yearly household income, before taxes? Less than $ 40K $41,000 - $80,000 $81,000 – $120,000 More than $120K If applicable, Please tell us a little about where you work: Question Title * 9. Occupation: Question Title * 10. Job Title: Question Title * 11. Company: Question Title * 12. Industry sector: Question Title * 13. Do you or any member of your family work for any of the following types of companies? A medical professional such as a doctor, nurse or pharmacist A marketing or marketing research firm A drug store or pharmacy A company that manufactures, distributes or sells medical or pharmaceutical products An advertising agency or public relations firm An HMO or health insurance company A newspaper/magazine publishing company, radio or TV broadcasting None of the above Question Title * 14. Did your parent or caregiver tell you about this study? No Yes (please type her/his name in this text box): Next