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Thank you for your interest in our upcoming focus group in Montgomery County on March 19. This information is for research and screening purposes only and will be kept confidential. It will not be shared, and you will not receive marketing offers as a result of completing this questionnaire. Upon completion of each group, participants will receive $100 in thanks for their time and opinions.

If you have any problems with this form, please contact
1. Please provide your contact information so we know how to get in touch with you.
2. 1. What is your age? *This question is required.
3. 2. What is your gender? *This question is required.
4. 3. What is your race or ethnicity? Mark all that apply. *This question is required.
5. 4. What is the highest level of education you have completed? *This question is required.