Houston Studies Late June 2015

1. Default Section

Plaza Research Houston is looking for diabetes patients age 40-64 to commit to a 30 day evaluation of an adherence program. This study will begin Monday, June 22nd, ending Friday, July 24th, 2015. If you qualify and are chosen to participate, you will receive $350 for participating in the 30-day study consisting of online activities, telephone interviews and a 90-minute focus group.

We are also looking for Males 25-35 years old to participate in a discussion on Beer. The study takes place at a Galleria-area hotel on Monday, June 29th, 2015 in the evening. If you qualify and are chosen to participate, you will receive $175 for 3-hours of your time (Plus Dinner).

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. (Required.)

Name:

ZIP:

Email Address:

Phone Number:

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2. Alternate Contact number

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3. What is your Employment Status? (Required.)

Please list the occupation, company and industry for all employed members of your household

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4. Generally speaking, is your occupation....

A professional or managerial role

A skilled technician

A secretarial, administrative or clerical role

A position in a creative field

A position in the armed forces

A position requiring manual labor

An educator

None of the above

Other (please specify)

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5. Please answer the following demographic questions. (Required.)

	Age range	Marital Status	Gender	Ethnicity	Education	Income
Demographic Information	Demographic Information Age range menu	Demographic Information Marital Status menu	Demographic Information Gender menu	Demographic Information Ethnicity menu	Demographic Information Education menu	Demographic Information Income menu

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6. What is your exact age?

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7. What is your current living situation?

With your parents

With a friend/friends

With your spouse

With your domestic partner/significant other

With your spouse/partner’s parents

Alone

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8. When was the last time, if ever, you participated in a focus group discussion or individual interview and what was the topic? (Required.)

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9. Do you want to answer question about Diabetes?

Yes

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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. (Required.)

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* 2. Alternate Contact number

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* 3. What is your Employment Status? (Required.)

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* 4. Generally speaking, is your occupation....

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* 5. Please answer the following demographic questions. (Required.)

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* 6. What is your exact age?

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* 7. What is your current living situation?

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* 8. When was the last time, if ever, you participated in a focus group discussion or individual interview and what was the topic? (Required.)

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* 9. Do you want to answer question about Diabetes?

1. Please provide us with the following information. We will be contacting you by telephone if you seem like a match. (Required.)

2. Alternate Contact number

3. What is your Employment Status? (Required.)

4. Generally speaking, is your occupation....

5. Please answer the following demographic questions. (Required.)

6. What is your exact age?

7. What is your current living situation?

8. When was the last time, if ever, you participated in a focus group discussion or individual interview and what was the topic? (Required.)

9. Do you want to answer question about Diabetes?