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Participate in a Focus Group
So we can match you to our studies, please fill out this form as completely as possible. We respect your privacy. Information that you provide in this form is kept strictly confidential.
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First Name:
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Last Name:
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Address:
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City:
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State:
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Zip:
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Telephone Number:
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Email Address:
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Date of Birth:
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Gender:
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What is your employment status?
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What is your Job Title?
(if Physician, please note type)
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Racial or ethnic background
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Other:
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Marital Status
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Highest Level of Education Completed
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Estimated Annual Household
Income Before Taxes
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Do you have children?
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How many children do you have?
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When were they born?
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Date that you last participated in a focus group:
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