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Email *
Name (first and last): *
Age: *
Gender *
Phone Number: *
Which of the following best describes your Ethnicity? *
What is your Highest Level of Education? *
Are you currently employed? If so, what is your current job title? *
Which of the Following Best Represents your Household Income? *
What STATE do you live in? *
What CITY do you live in? *
What COUNTY do you live in? *
How long have you been a resident in your current city?
Clear selection
Please tell me of list of health systems or hospitals. For each one, please tell me how familiar you are with each facility
Very familiar
Somewhat familiar
A little familiar
Not at all
Dignity Health
Dominican Hospital
Kaiser Permanente
Sutter Health
Watsonville Hospital
Community Health Center of Monterey Peninsula
Which (if any) of the following have you visited in the past 5 years for you or a loved one?
Which of the following best describes your current health insurance coverage
Clear selection
How many children living under the age of 21 do you have living in your household?
Clear selection
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