Caregivers
This survey is a pre-screening survey to see eligible for a market research Focus Group . You do NOT get compensated for taking this online screener. IF you pre-qualify, you will receive a text, phone call or email from a Recruiter to call our office.  Thank you.

Location: Manhattan (Herald Square)
Date: Wed/March 9th
Time: 12:00PM-2:15PM, 3:00PM-5:15PM OR 5:45-8:00PM
Compensation: $200 Visa Gift Card (if chosen)

Times are for reference only, booked by available quotas.
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First Name *
Last Name *
Your Age *
Your Age *
Gender *
Ethnicity/Race *
Required
Are you Spanish, Hispanic or Latina/Latina? *
Email *
Cell-Phone Number *
Best Number to Text *
Cell Phone Carrier *
Alternate Number *
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? *
State *
The County you Live in (i.e., Lehigh) *
The County you Work in (i.e., Lehigh) *
Your Zip Code where you live *
The Make/Model of your Cell Phone *
Are you currently *
If you are a Student, are you
Clear selection
What is the highest level of education you have completed? *
If you are currently working, please briefly describe your employment *
What is your job title? *
What is the name of the company/organization you work for? *
If you are currently working, what industry do you work in? *
What best represents your households annual income before taxes? (By this we mean all income brought into the home by all household members) *
Marital Status *
What one radio station is your favorite station to listen to for Music? *
What one radio station is your Second favorite station to listen to for Music? *
What one radio station is your Third favorite station to listen to for Music? *
Do you personally have any children currently living in your home under the age of 18? *
If yes, how old are they? *
Required
If yes, what is their age/gender? *
2. Do you or anyone immediate family work in, or are affiliated with, the fields of market research, advertising, TV or print      media, marketing, manufacturer / distributor / retailer of OTC or Rx meds, a pharma company, hospital, clinic, doctor’s office      or gov’t regulatory agency? *
3. Do you help care for someone who has been diagnosed with Down syndrome?   *
4. How old is this person with Down syndrome?   *
5. Is the person with Down syndrome is male or female? *
6a. What is your relationship to this individual?   *
6b. How would you describe your role in terms of the day-to-day care for this person with Down syndrome: *
6c. Where does the individual with Down syndrome currently live?   *
7. How long have you been the primary caregiver for this person with Down syndrome? *
ie. 2 yrs. If Not Applicable, enter N/A
 8. How many other people living in your home are also a caregiver to this individual with Down syndrome? *
9. Do you speak with the doctor/nurse regarding medicine, treatment, etc. WITH OR WITHOUT THIS PERSON and provide       substantial input into the medical decisions for this person? *
10a. How was the person that you care for diagnosed as having Down syndrome? *
10b. Currently, what is your impression of your child with Down syndrome’s level of functioning?   *
11. Thinking about their functional abilities, which of these currently applies to him/her?   *
Required
12a. Is he/she currently receiving any therapies for Down syndrome?   *
12b. What therapies are they currently receiving for Down syndrome?   *
If Not Applicable, enter N/A
12b-2. What medications or prescriptions is he/she currently using, for any reason? *
If Not Applicable, enter N/A
12c. Is he/she participating in a drug trial for a medication related to Down syndrome? *
12d. What is the name of the drug trial? *
If Not Applicable, enter N/A
19. Please tell me, what type of medical health insurance do you currently have?   *
Required
20.  If you could have dinner with any person – real or fictional, current or historical, who would you choose and why? *
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