Prostate Cancer
This questionnaire is a pre-screener to seek eligibility for a market research project. You do NOT get compensated for filling out this form. If you pre-qualify, you will receive a text or email from a Recruiter to call our office.  

$75.00 - 1 Hour Zoom VideoConference

Open to Men Diagnosed with Prostate Cancer
and
Caregivers of Men Diagnosed with Prostate Cancer

Interview schedule:
Thurs, 8/12 - Mon, 8/16/2021
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Email *
First Name *
Last Name *
Advanced Opinions communicates via text may we text to communicate with you? * *
Advanced Opinions communicates via email may we email you to communicate with you? * *
Last Name *
State * *
Zip Code (Home) *
Enter 5 Digit Zip Code (Example: 12345)
Cell Phone Number *
Enter phone number as 9995551212 (no dashes, spaces, etc.)
What is your date of Birth? * *
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DD
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Your age *
Ethnicity/Race *
Gender *
Which of the following best represents your current marital status? * *
Last Level of Education you Completed *
Household Income (This is not your Personal Income, but the Income of the Household Example: 4 People living in a household related/unrelated Person1: Student w/PT Job paid off the books earns $200week + receives $1,000 month from parents for rent = $22,400 ) Person2: Disability $200week=$10,400yr + Person3: FT delivery service Job paid off the books earns $200week =$10,400yr + Person4 PT Cook $200week=$10,400yr Total Household Income $52,600) *
Employment Status *
If you are a Student, Homemaker, Retired, Unemployed, Not working or Disabled and work FT or PT, please choose if you work either FT or PT - for Self-employed/Freelancers choose FT if you average 30 or more hours in an average week, choose PT if you average less than 30 hours in an average week
We are always seeking opinions from both those born in the USA as well as outside of the USA, Where you born.... *
Do you have children living in your household? *
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