SF Upcoming PAID study on MEDICAL CONDITIONS - September 2011

1. SF Upcoming PAID study on Medical Conditions - September 2011

Thank you for taking the time to answer these brief questions. As always, we appreciate your input as a valuable Plaza Research respondent. We have a new study on Medical Conditions that you may be interested in.

We are currently looking for males and females ages 18 years and older who suffer from a certain Medical Condition. This study is a 1.5-hour focus group discussion that pays a $125 honorarium for your participation. This study is taking place in downtown San Francisco.

IF you qualify based on the answers provided THEN you will receive a call back. However due to the popularity of our surveys and groups, we can't contact everyone.

Please note that all responses will be returned on a first come, first served basis until the studies are full.

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* 1. Contact Information

Name

Cell Phone

Home Phone

Work Phone

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* 2. Employment Information

Job Title

Company Name

Industry

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* 3. What is your gender?

Male

Female

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* 4. Which of the following categories include your age?

18-24

25-34

35-44

45-64

65 and over

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* 5. What is the last year of education that you have completed?

Less than high school graduate

High school graduate/GED

Some college

College graduate

Post-graduate

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* 6. What is your ethnic background?

Caucasian

African American

Asian/Pacific Islander

Hispanic/Latino

Native American

Multicultural

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* 7. What is your current employment status?

Full-time

Part-time

Student

Homemaker

Retired

Unemployed

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* 8. What is the make/model of the printer you use for work/business?

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* 9. Have you ever been diagnosed by a doctor with any of the following conditions? Please select all that apply.

Sinusitis

Migraine Headaches

Asthma

Allergies

None of the above

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* 10. Approximately how long do your symptoms to the above condition(s) last?

Less than 4 weeks

4-7 weeks

8 weeks or longer

**IMPORTANT: PLEASE PUSH THE "DONE" BUTTON AT THE BOTTOM OF THIS SCREEN. YOUR ANSWERS WILL NOT BE SAVED WITHOUT DOING SO!**

Thank you for participating in our survey. IF you qualify based on the answers provided THEN you will receive a call back. However due to the popularity of our surveys and groups, we can't contact everyone. Please note that all responses will be returned on a first come, first served basis until the studies are full.

*****REFERRALS ARE GREATLY APPRECIATED!*****

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* 1. Contact Information

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* 2. Employment Information

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* 3. What is your gender?

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* 4. Which of the following categories include your age?

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* 5. What is the last year of education that you have completed?

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* 6. What is your ethnic background?

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* 7. What is your current employment status?

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* 8. What is the make/model of the printer you use for work/business?

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* 9. Have you ever been diagnosed by a doctor with any of the following conditions? Please select all that apply.

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* 10. Approximately how long do your symptoms to the above condition(s) last?

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* 11. FOR COMPANY USE ONLY
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