Trillium Member Survey Question Title * 1. Please tell us your first name and the city you live in. Name: City/Town: Question Title * 2. Tell us about yourself:Age: 18-25 26-35 36-45 46-62 63+ Question Title * 3. Please choose one: Female Male Prefer not to answer Question Title * 4. Ethnicity? (Please select all that apply.) American Indian or Alaskan Native Asian or Pacific Islander Black or African American Hispanic or Latino White/Caucasian Prefer not to answer Other (please specify) Question Title * 5. Are you and/or your children enrolled in an insurance plan? You Your Child(ren) Oregon Health Plan (OHP) Oregon Health Plan (OHP) You Oregon Health Plan (OHP) Your Child(ren) Private Insurance Private Insurance You Private Insurance Your Child(ren) Other Other You Other Your Child(ren) Don't have insurance Don't have insurance You Don't have insurance Your Child(ren) Question Title * 6. A primary health care provider is the one you would see if you need a check-up, want advice about a health problem, or get sick or hurt. Do you have a primary health care provider? Yes No Next