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Focus Group Pre-screener

Thank you for your interest in our upcoming focus groups. 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 $80 in thanks for their time and opinions.

If you have any problems with this form, please contact susan@opinionworks.com.

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1. Please provide your contact information so we know how to get in touch with you. *This question is required.
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? Please select all that apply. *This question is required.
5. 4. Do you have health insurance or some other kind of coverage for your health care? *This question is required.
6. 5. Just to confirm, right now, are you covered by an employer’s health plan, your own individual policy that you pay for, Medicare, VA, Medicaid or another public assistance program, or no health care coverage?