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Email
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Your email
What is your name?
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Your answer
What is your race or ethinicity? Please select all that apply.
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Black or African American
White
Asian
Member of another group
Hispanic or Latino
Required
Did you assist or were you present when a recently deceased person was making healthcare decisions?
*
Yes
No
Was the deceased person 65 years or older?
*
Yes
No
What month and year did the person pass away?
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Your answer
How old are you?
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Your answer
What state and city do you currently live in?
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Your answer
What is the best phone number to reach you?
Your answer
How did you learn about our study?
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Your answer
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