Screener Sample - Healthcare

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1. Do you or any member of your household work for any of the following? [MULTIPLE RESPONSE]
   • Market research firm or market research department
   • Healthcare or insurance company
   • Web/software development or web/software design
   • Mobile development, design, manufacturing
   • Usability or product design industry
   • Analyst and/or journalist specializing in healthcare or insurance industry
   • Management Consulting Company
   • None of the above
2. Are you? [SINGLE RESPONSE]
   • Male
   • Female
3. What is your age? [SINGLE RESPONSE]
   • Under 18 [TERMINATE]
   • 18 to 24
   • 25 to 34
   • 35 to 44
   • 45 to 54
   • 55 to 64
   • 65 or older
   • Prefer not to say [TERMINATE]
4. Which of the following best describes you? [SINGLE RESPONSE]
   • Single, never married
   • Currently married
   • Living with partner but not married
   • Separated
   • Divorced
   • Widowed
   • Prefer not to say
5. Indicate the HIGHEST level of education (or equivalent) you have completed. [SINGLE RESPONSE]
   • Some high school or less
   • High school graduate
   • Attended college less than one year
   • Attended college 1-3 years
   • Graduated from 4 year college
   • Post graduate study without degree
   • Master's degree
   • Doctoral degree/Professional degree
   • None of the above
6. Which of the following best describes your race? [MULTIPLE RESPONSE]
   • White
   • Black/African-American
   • American Indian or Alaska Native
   • Native Hawaiian or Pacific Islander
   • Asian
   • Other
   • Prefer not to answer
7. Are you of Hispanic or Latino descent? [SINGLE RESPONSE]
   • Yes
   • No
   • Prefer not to answer
8. How many people, including yourself, are currently living in your household? [SINGLE RESPONSE]
   • One [SKIP TO S10]
   • Two
   • Three
   • Four
   • Five
   • Six
   • Seven
   • Eight or more
   • Prefer not to answer
9. How many children under the age of 18 are currently living in your household? [SINGLE RESPONSE]
   • None
   • One
   • Two
   • Three
   • Four
   • Five or more
   • Prefer not to answer
10. Which of the following best describes your current employment status? [SINGLE RESPONSE]
    • Employed full-time
    • Employed part-time
    • Homemaker
    • Student
    • Looking for work
    • Retired
    • Other
11. What is your total annual household income? [SINGLE RESPONSE]
    • Less than $15,000
    • $15,000 - $24,999
    • $25,000 - $34,999
    • $35,000 - $49,999
    • $50,000 - $74,999
    • $75,000 - $99,999
    • $100,000 - $124,999
    • $125,000 - $149,999
    • $150,000 - $199,999
    • $200,000 or more
    • Prefer not to answer
12. In which state do you currently live?[DROPDOWN MENU] [SINGLE RESPONSE] [USE FIPS CODES FOR REPORTING]
    • 01 Alabama
    • 02 Alaska
    • 04 Arizona
    • 05 Arkansas
    • 06 California
    • 08 Colorado
    • 09 Connecticut
    • 10 Delaware
    • 11 District of Columbia
    • 12 Florida
    • 13 Georgia
    • 15 Hawaii
    • 16 Idaho
    • 17 Illinois
    • 18 Indiana
    • 19 Iowa
    • 20 Kansas
    • 21 Kentucky
    • 22 Louisiana
    • 23 Maine
    • 24 Maryland
    • 25 Massachusetts
    • 26 Michigan
    • 27 Minnesota
    • 28 Mississippi
    • 29 Missouri
    • 30 Montana
    • 31 Nebraska
    • 32 Nevada
    • 33 New Hampshire
    • 34 New Jersey
    • 35 New Mexico
    • 36 New York
    • 37 North Carolina
    • 38 North Dakota
    • 39 Ohio
    • 40 Oklahoma
    • 41 Oregon
    • 42 Pennsylvania
    • 44 Rhode Island
    • 45 South Carolina
    • 46 South Dakota
    • 47 Tennessee
    • 48 Texas
    • 49 Utah
    • 50 Vermont
    • 51 Virginia
    • 53 Washington
    • 54 West Virginia
    • 55 Wisconsin
    • 56 Wyoming
    • 99 Other
13. How would you best describe your role in making health care related decisions for your household (such as choosing a health insurer, doctor or hospital)? [SINGLE RESPONSE]
    • I am the primary decision-maker
    • I share equally in the decision-making process
    • I contribute to the decision, but someone else contributes more [TERMINATE]
    • I am not involved in the decision [TERMINATE]
    • Other (Specify) [TERMINATE]
14. What type of health insurance do you currently have? If you have more than one, please select your primary health insurance. [SINGLE RESPONSE]
    Health Insurance through an Employer
    • Through my/my spouse’s current/former employer or union
    • Through my parent/guardian’s employer or union
    • Purchased for my small business from an insurance company, through an agent or broker or the SHOP Exchange
    Health Insurance from the Government
    • Medicare (the health insurance for persons 65 years old and over or persons with disabilities)
    • Medicaid
    • Coverage by TRICARE, CHAMPUS, CHAPVA, VA, military health care, or Indian Health Service
    Health Insurance that you or your family purchases
    • From an insurance company through the government Health Insurance Exchange (Obamacare, healthcare.gov) or a state exchange
    • Directly from an insurance company
    • Through an agent or broker
    Other type of insurance
    • I do not have health insurance at this time
    • I’m not sure
15. Would your plan be considered a PPO, HMO, or CDHP – or something else? If you’re not sure, it should say on your insurance card. [SINGLE RESPONSE]
    • PPO (Preferred Provider Organization)
    • HMO (Health Maintenance Organization)
    • CDHP or HDHP (Consumer Driven Health Plan or High Deductible Health Plan.) A plan with a deductible of $1,250 or more for an individual/$2,500 or more for a family. These plans may include a spending account such as an HRA or HSA
    • Not sure
    • Other (Specify)

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