CTOpinion - Hartford Research Sign Up
Filling out the survey does not automatically mean that you will be selected for the study.
Your first name:
Your last name:
Your year of birth: (Example: 1983)
Are you male or female?
Please enter the year of birth (example: 2015 2018) for the children who live in your household. (Only children younger than 18.)
Your current job or occupation (You can also enter homemaker, retired, student, or not currently employed) :
Where do you get your health insurance?:
I don't currently have health insurance
Through the Affordable Healthcare Act
Through my employer or my spouse's employer
I buy it on my own, but not through the Affordable Healthcare Act
Medicare or a Supplemental policy
Medicaid or HUSKY
Through my parents
Government or Military
What is the name of your health insurance company? (if none, write none) :
What is your highest level of education?
Less that High School
High School or GED
Some College or Technical School
What is the total income of everyone in your household? :
Less than $25,000
$25,000 to $49,000
$50,000 to $99,000
$100,000 to $150,000
What is the best phone number where we can call you ?
What is your 5 digit zip code?
We like a mix of people for our research projects. Are you :
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