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Submission: On April 20 via manual from US — Scanned from DE
Submission: On April 20 via manual from US — Scanned from DE
Form analysis 1 forms found in the DOM
Name: surveyForm — POST
<form name="surveyForm" action="" method="post" enctype="multipart/form-data" novalidate="" data-survey-page-form="">
<div class="questions clearfix">
<div class="question-click-shield" tabindex="-1" style="height: 570px; width: 896px; display: none;"></div>
<div class="question-row clearfix" tabindex="-1">
<div data-question-type="open_ended_multi" data-rq-question-type="open_ended_multi" class="question-container
">
<div id="question-field-127559090" data-qnumber="1" data-qdispnumber="1" data-question-id="127559090" class=" question-open-ended-multi qn question multi">
<h3 class="screenreader-only">Question Title</h3>
<div class="text-input-group question-fieldset question-legend">
<h4 id="question-title-127559090" class=" question-title-container ">
<span class="required-asterisk notranslate"> * </span>
<span class="question-number notranslate"> 1<span class="question-dot">.</span>
</span>
<span class="user-generated notranslate
"> Murray Hill National is conducting a study on Medicare and would like you to participate. If you qualify for this study, we are offering an incentive. Please be assured that we are not selling anything and the information we
gather will remain confidential and be used for research purposes only. We have a few questions to ask before providing more details and determining if you qualify to participate.</span>
</h4>
<div class="question-body clearfix notranslate ">
<div class="text-input-container clearfix">
<label class="question-body-font-theme answer-label user-generated " for="127559090_955508281" style="width:20%;"> Name </label><input id="127559090_955508281" name="127559090_955508281" type="text" class="text" maxlength="20000"
size="50" data-sm-open-single="">
</div>
<div class="text-input-container clearfix">
<label class="question-body-font-theme answer-label user-generated " for="127559090_955508282" style="width:20%;"> Company </label><input id="127559090_955508282" name="127559090_955508282" type="text" class="text" maxlength="20000"
size="50" data-sm-open-single="">
</div>
<div class="text-input-container clearfix">
<label class="question-body-font-theme answer-label user-generated " for="127559090_955508283" style="width:20%;"> Address </label><input id="127559090_955508283" name="127559090_955508283" type="text" class="text" maxlength="20000"
size="50" data-sm-open-single="">
</div>
<div class="text-input-container clearfix">
<label class="question-body-font-theme answer-label user-generated " for="127559090_955508284" style="width:20%;"> Address 2 </label><input id="127559090_955508284" name="127559090_955508284" type="text" class="text" maxlength="20000"
size="50" data-sm-open-single="">
</div>
<div class="text-input-container clearfix">
<label class="question-body-font-theme answer-label user-generated " for="127559090_955508285" style="width:20%;"> City/Town </label><input id="127559090_955508285" name="127559090_955508285" type="text" class="text" maxlength="20000"
size="50" data-sm-open-single="">
</div>
<div class="text-input-container clearfix">
<label class="question-body-font-theme answer-label user-generated " for="127559090_955508286" style="width:20%;"> State/Province </label><input id="127559090_955508286" name="127559090_955508286" type="text" class="text"
maxlength="20000" size="50" data-sm-open-single="">
</div>
<div class="text-input-container clearfix">
<label class="question-body-font-theme answer-label user-generated " for="127559090_955508287" style="width:20%;"> Zip/Postal Code </label><input id="127559090_955508287" name="127559090_955508287" type="text" class="text"
maxlength="20000" size="50" data-sm-open-single="">
</div>
<div class="text-input-container clearfix">
<label class="question-body-font-theme answer-label user-generated " for="127559090_955508288" style="width:20%;"> Country </label><input id="127559090_955508288" name="127559090_955508288" type="text" class="text" maxlength="20000"
size="50" data-sm-open-single="">
</div>
<div class="text-input-container clearfix">
<label class="question-body-font-theme answer-label user-generated " for="127559090_955508289" style="width:20%;"> Email address </label><input id="127559090_955508289" name="127559090_955508289" type="text" class="text"
maxlength="20000" size="50" data-sm-open-single="">
</div>
<div class="text-input-container clearfix">
<label class="question-body-font-theme answer-label user-generated " for="127559090_955508290" style="width:20%;"> Phone number </label><input id="127559090_955508290" name="127559090_955508290" type="text" class="text"
maxlength="20000" size="50" data-sm-open-single="">
</div>
</div>
</div>
</div>
</div>
<button id="127559090-ok" class="new-button ok-button user-generated notranslate hide" type="submit"> OK </button>
</div>
<div class="question-click-shield" tabindex="-1" style="height: 269px; width: 896px;"></div>
<div class="question-row clearfix overlay
" tabindex="-1">
<div data-question-type="single_choice_vertical" data-rq-question-type="single_choice_vertical" class="question-container
">
<div id="question-field-127560038" data-qnumber="2" data-qdispnumber="2" data-question-id="127560038" class=" question-single-choice-radio qn question vertical">
<h3 class="screenreader-only">Question Title</h3>
<fieldset class=" question-fieldset" data-radio-button-group="">
<legend class="question-legend">
<h4 id="question-title-127560038" class="
question-title-container ">
<span class="required-asterisk notranslate"> * </span>
<span class="question-number notranslate"> 2<span class="question-dot">.</span>
</span>
<span class="user-generated notranslate
"> Do you identify as... <br><br></span>
</h4>
</legend>
<div class="question-body clearfix notranslate ">
<div class="">
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-127560038">
<input id="127560038_955514307" aria-labelledby="127560038_955514307_label" name="127560038" type="radio" role="radio" class="radio-button-input " value="955514307" aria-checked="false">
<label data-sm-radio-button-label="" id="127560038_955514307_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="127560038_955514307">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> Male </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-127560038">
<input id="127560038_955514308" aria-labelledby="127560038_955514308_label" name="127560038" type="radio" role="radio" class="radio-button-input " value="955514308" aria-checked="false">
<label data-sm-radio-button-label="" id="127560038_955514308_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="127560038_955514308">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> Female </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-127560038">
<input id="127560038_955514309" aria-labelledby="127560038_955514309_label" name="127560038" type="radio" role="radio" class="radio-button-input " value="955514309" aria-checked="false">
<label data-sm-radio-button-label="" id="127560038_955514309_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="127560038_955514309">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> Other (Please specify) </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-127560038">
<input id="127560038_955514310" aria-labelledby="127560038_955514310_label" name="127560038" type="radio" role="radio" class="radio-button-input " value="955514310" aria-checked="false">
<label data-sm-radio-button-label="" id="127560038_955514310_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="127560038_955514310">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> Rather not say </span>
</label>
</div>
</div>
</div>
</div>
</fieldset>
</div>
</div>
<button id="127560038-ok" class="new-button ok-button user-generated notranslate hide" type="submit"> OK </button>
</div>
<div class="question-click-shield" tabindex="-1" style="height: 102px; width: 896px;"></div>
<div class="question-row clearfix overlay
" tabindex="-1">
<div data-question-type="open_ended_single" data-rq-question-type="open_ended" class="question-container
">
<div id="question-field-127560089" data-qnumber="3" data-qdispnumber="3" data-question-id="127560089" class=" question-open-ended-single qn question single">
<h3 class="screenreader-only">Question Title</h3>
<div class=" question-fieldset question-legend">
<h4 id="question-title-127560089" class=" question-title-container ">
<span class="required-asterisk notranslate"> * </span>
<span class="question-number notranslate"> 3<span class="question-dot">.</span>
</span>
<span class="user-generated notranslate
"> In which state do you live?</span>
</h4>
<div class="question-body clearfix notranslate ">
<div id="open-ended-single_127560089" data-question-id="127560089" data-response="" data-sm-open-single="" maxlength="20000" data-ng="true" data-size="50" data-labeledby="question-title-127560089">
<div class="question-body open-ended-single"><input aria-labelledby="question-title-127560089" id="127560089" aria-required="false" data-sm-open-single="true" maxlength="20000" class="wds-input wds-input--lg qt-input_text text"
name="127560089" size="50" value=""></div>
</div>
</div>
</div>
</div>
</div>
<button id="127560089-ok" class="new-button ok-button user-generated notranslate hide" type="submit"> OK </button>
</div>
<div class="question-click-shield" tabindex="-1" style="height: 196px; width: 896px;"></div>
<div class="question-row clearfix overlay
" tabindex="-1">
<div data-question-type="single_choice_vertical_two_col" data-rq-question-type="single_choice_vertical_two_col" class="question-container
">
<div id="question-field-127560130" data-qnumber="4" data-qdispnumber="4" data-question-id="127560130" class=" question-single-choice-radio qn question vertical_two_col">
<h3 class="screenreader-only">Question Title</h3>
<fieldset class=" question-fieldset" data-radio-button-group="">
<legend class="question-legend">
<h4 id="question-title-127560130" class="
question-title-container ">
<span class="required-asterisk notranslate"> * </span>
<span class="question-number notranslate"> 4<span class="question-dot">.</span>
</span>
<span class="user-generated notranslate
"> What was your annual household income (before taxes) in the past year?</span>
</h4>
</legend>
<div class="question-body clearfix notranslate ">
<div class="answer-option-col
answer-option-col-2">
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-127560130">
<input id="127560130_955514716" aria-labelledby="127560130_955514716_label" name="127560130" type="radio" role="radio" class="radio-button-input " value="955514716" aria-checked="false">
<label data-sm-radio-button-label="" id="127560130_955514716_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="127560130_955514716">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> Under $20,000 </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-127560130">
<input id="127560130_955514717" aria-labelledby="127560130_955514717_label" name="127560130" type="radio" role="radio" class="radio-button-input " value="955514717" aria-checked="false">
<label data-sm-radio-button-label="" id="127560130_955514717_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="127560130_955514717">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> $20,000 to $49,999 </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-127560130">
<input id="127560130_955514718" aria-labelledby="127560130_955514718_label" name="127560130" type="radio" role="radio" class="radio-button-input " value="955514718" aria-checked="false">
<label data-sm-radio-button-label="" id="127560130_955514718_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="127560130_955514718">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> $50,000 to $79,999 </span>
</label>
</div>
</div>
</div>
<div class="answer-option-col
answer-option-col-2">
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-127560130">
<input id="127560130_955514719" aria-labelledby="127560130_955514719_label" name="127560130" type="radio" role="radio" class="radio-button-input " value="955514719" aria-checked="false">
<label data-sm-radio-button-label="" id="127560130_955514719_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="127560130_955514719">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> $80,000 to $109,999 </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-127560130">
<input id="127560130_955514720" aria-labelledby="127560130_955514720_label" name="127560130" type="radio" role="radio" class="radio-button-input " value="955514720" aria-checked="false">
<label data-sm-radio-button-label="" id="127560130_955514720_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="127560130_955514720">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> $110,000 to $139,999 </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-127560130">
<input id="127560130_955514721" aria-labelledby="127560130_955514721_label" name="127560130" type="radio" role="radio" class="radio-button-input " value="955514721" aria-checked="false">
<label data-sm-radio-button-label="" id="127560130_955514721_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="127560130_955514721">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> $140,000 or more </span>
</label>
</div>
</div>
</div>
</div>
</fieldset>
</div>
</div>
<button id="127560130-ok" class="new-button ok-button user-generated notranslate hide" type="submit"> OK </button>
</div>
<div class="question-click-shield" tabindex="-1" style="height: 148px; width: 896px;"></div>
<div class="question-row clearfix overlay
" tabindex="-1">
<div data-question-type="single_choice_vertical" data-rq-question-type="single_choice_vertical" class="question-container
">
<div id="question-field-127560145" data-qnumber="5" data-qdispnumber="5" data-question-id="127560145" class=" question-single-choice-radio qn question vertical">
<h3 class="screenreader-only">Question Title</h3>
<fieldset class=" question-fieldset" data-radio-button-group="">
<legend class="question-legend">
<h4 id="question-title-127560145" class="
question-title-container ">
<span class="required-asterisk notranslate"> * </span>
<span class="question-number notranslate"> 5<span class="question-dot">.</span>
</span>
<span class="user-generated notranslate
"> Do you own a mobile phone?</span>
</h4>
</legend>
<div class="question-body clearfix notranslate ">
<div class="">
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-127560145">
<input id="127560145_955514784" aria-labelledby="127560145_955514784_label" name="127560145" type="radio" role="radio" class="radio-button-input " value="955514784" aria-checked="false">
<label data-sm-radio-button-label="" id="127560145_955514784_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="127560145_955514784">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> Yes </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-127560145">
<input id="127560145_955514785" aria-labelledby="127560145_955514785_label" name="127560145" type="radio" role="radio" class="radio-button-input " value="955514785" aria-checked="false">
<label data-sm-radio-button-label="" id="127560145_955514785_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="127560145_955514785">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> No </span>
</label>
</div>
</div>
</div>
</div>
</fieldset>
</div>
</div>
<button id="127560145-ok" class="new-button ok-button user-generated notranslate hide" type="submit"> OK </button>
</div>
<div class="question-click-shield" tabindex="-1" style="height: 196px; width: 896px;"></div>
<div class="question-row clearfix overlay
" tabindex="-1">
<div data-question-type="single_choice_vertical" data-rq-question-type="single_choice_vertical" class="question-container
">
<div id="question-field-127560183" data-qnumber="6" data-qdispnumber="6" data-question-id="127560183" class=" question-single-choice-radio qn question vertical">
<h3 class="screenreader-only">Question Title</h3>
<fieldset class=" question-fieldset" data-radio-button-group="">
<legend class="question-legend">
<h4 id="question-title-127560183" class="
question-title-container ">
<span class="required-asterisk notranslate"> * </span>
<span class="question-number notranslate"> 6<span class="question-dot">.</span>
</span>
<span class="user-generated notranslate
"> Which of the following statements best describes your level of comfort with using a mobile phone?</span>
</h4>
</legend>
<div class="question-body clearfix notranslate ">
<div class="">
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-127560183">
<input id="127560183_955515055" aria-labelledby="127560183_955515055_label" name="127560183" type="radio" role="radio" class="radio-button-input " value="955515055" aria-checked="false">
<label data-sm-radio-button-label="" id="127560183_955515055_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="127560183_955515055">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> I find it easy to use my mobile phone and navigate the various features </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-127560183">
<input id="127560183_955515056" aria-labelledby="127560183_955515056_label" name="127560183" type="radio" role="radio" class="radio-button-input " value="955515056" aria-checked="false">
<label data-sm-radio-button-label="" id="127560183_955515056_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="127560183_955515056">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> I sometimes find it challenging to use certain features on my mobile phone </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-127560183">
<input id="127560183_955515057" aria-labelledby="127560183_955515057_label" name="127560183" type="radio" role="radio" class="radio-button-input " value="955515057" aria-checked="false">
<label data-sm-radio-button-label="" id="127560183_955515057_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="127560183_955515057">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> I find it challenging to use my mobile phone and often need assistance </span>
</label>
</div>
</div>
</div>
</div>
</fieldset>
</div>
</div>
<button id="127560183-ok" class="new-button ok-button user-generated notranslate hide" type="submit"> OK </button>
</div>
<div class="question-click-shield" tabindex="-1" style="height: 148px; width: 896px;"></div>
<div class="question-row clearfix overlay
" tabindex="-1">
<div data-question-type="single_choice_vertical" data-rq-question-type="single_choice_vertical" class="question-container
">
<div id="question-field-127560217" data-qnumber="7" data-qdispnumber="7" data-question-id="127560217" class=" question-single-choice-radio qn question vertical">
<h3 class="screenreader-only">Question Title</h3>
<fieldset class=" question-fieldset" data-radio-button-group="">
<legend class="question-legend">
<h4 id="question-title-127560217" class="
question-title-container ">
<span class="required-asterisk notranslate"> * </span>
<span class="question-number notranslate"> 7<span class="question-dot">.</span>
</span>
<span class="user-generated notranslate
"> Are you aware of Medicare health insurance?</span>
</h4>
</legend>
<div class="question-body clearfix notranslate ">
<div class="">
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-127560217">
<input id="127560217_955515234" aria-labelledby="127560217_955515234_label" name="127560217" type="radio" role="radio" class="radio-button-input " value="955515234" aria-checked="false">
<label data-sm-radio-button-label="" id="127560217_955515234_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="127560217_955515234">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> Yes </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-127560217">
<input id="127560217_955515235" aria-labelledby="127560217_955515235_label" name="127560217" type="radio" role="radio" class="radio-button-input " value="955515235" aria-checked="false">
<label data-sm-radio-button-label="" id="127560217_955515235_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="127560217_955515235">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> No </span>
</label>
</div>
</div>
</div>
</div>
</fieldset>
</div>
</div>
<button id="127560217-ok" class="new-button ok-button user-generated notranslate hide" type="submit"> OK </button>
</div>
<div class="question-click-shield" tabindex="-1" style="height: 246px; width: 896px;"></div>
<div class="question-row clearfix overlay
" tabindex="-1">
<div data-question-type="single_choice_vertical" data-rq-question-type="single_choice_vertical" class="question-container
">
<div id="question-field-127560289" data-qnumber="8" data-qdispnumber="8" data-question-id="127560289" class=" question-single-choice-radio qn question vertical">
<h3 class="screenreader-only">Question Title</h3>
<fieldset class=" question-fieldset" data-radio-button-group="">
<legend class="question-legend">
<h4 id="question-title-127560289" class="
question-title-container ">
<span class="required-asterisk notranslate"> * </span>
<span class="question-number notranslate"> 8<span class="question-dot">.</span>
</span>
<span class="user-generated notranslate
"> Which of the following statements reflects your current enrolment status with regard to Medicare health insurance? <br><br></span>
</h4>
</legend>
<div class="question-body clearfix notranslate ">
<div class="">
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-127560289">
<input id="127560289_955515728" aria-labelledby="127560289_955515728_label" name="127560289" type="radio" role="radio" class="radio-button-input " value="955515728" aria-checked="false">
<label data-sm-radio-button-label="" id="127560289_955515728_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="127560289_955515728">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> I am currently enrolled in Medicare health insurance </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-127560289">
<input id="127560289_955515729" aria-labelledby="127560289_955515729_label" name="127560289" type="radio" role="radio" class="radio-button-input " value="955515729" aria-checked="false">
<label data-sm-radio-button-label="" id="127560289_955515729_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="127560289_955515729">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> I am not currently enrolled in Medicare health insurance, but I am planning to enroll soon </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-127560289">
<input id="127560289_955515730" aria-labelledby="127560289_955515730_label" name="127560289" type="radio" role="radio" class="radio-button-input " value="955515730" aria-checked="false">
<label data-sm-radio-button-label="" id="127560289_955515730_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="127560289_955515730">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> I am not enrolled in Medicare health insurance, and I have no plans to enroll in the near future </span>
</label>
</div>
</div>
</div>
</div>
</fieldset>
</div>
</div>
<button id="127560289-ok" class="new-button ok-button user-generated notranslate hide" type="submit"> OK </button>
</div>
<div class="question-click-shield" tabindex="-1" style="height: 335px; width: 896px;"></div>
<div class="question-row clearfix overlay
" tabindex="-1">
<div data-question-type="multiple_choice_vertical" data-rq-question-type="multiple_choice_vertical" class="question-container
">
<div id="question-field-127560391" data-qnumber="9" data-qdispnumber="9" data-question-id="127560391" class=" question-multiple-choice qn question vertical">
<h3 class="screenreader-only">Question Title</h3>
<fieldset class=" question-fieldset">
<legend class="question-legend">
<h4 id="question-title-127560391" class="
question-title-container ">
<span class="required-asterisk notranslate"> * </span>
<span class="question-number notranslate"> 9<span class="question-dot">.</span>
</span>
<span class="user-generated notranslate
"> Which of the following Medicare Health insurance providers are you considering enrolling with?</span>
</h4>
</legend>
<div class="question-body clearfix notranslate ">
<div class="">
<div class="answer-option-cell
">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="127560391_955516512" name="127560391[]" type="checkbox" class="checkbox-button-input " value="955516512">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="127560391_955516512">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> Aetna Medicare </span>
</label>
</div>
</div>
<div class="answer-option-cell
">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="127560391_955516513" name="127560391[]" type="checkbox" class="checkbox-button-input " value="955516513">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="127560391_955516513">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> UnitedHealthcare </span>
</label>
</div>
</div>
<div class="answer-option-cell
">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="127560391_955516514" name="127560391[]" type="checkbox" class="checkbox-button-input " value="955516514">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="127560391_955516514">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> Cigna </span>
</label>
</div>
</div>
<div class="answer-option-cell
">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="127560391_955516515" name="127560391[]" type="checkbox" class="checkbox-button-input " value="955516515">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="127560391_955516515">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> Humana </span>
</label>
</div>
</div>
</div>
<div class="other-answer-container other-answer-option-container">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="127560391_955516516" name="127560391[]" type="checkbox" class="checkbox-button-input " value="955516516" data-other-answer="">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="127560391_955516516">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> Other (please specify) </span>
</label>
</div>
<input id="127560391_other" name="127560391_other" type="text" class="text other-answer-text" maxlength="20000" size="50" aria-label="Other (please specify)" data-other-text="">
</div>
</div>
</fieldset>
</div>
</div>
<button id="127560391-ok" class="new-button ok-button user-generated notranslate hide" type="submit"> OK </button>
</div>
<div class="question-click-shield" tabindex="-1" style="height: 362px; width: 896px;"></div>
<div class="question-row clearfix overlay
" tabindex="-1">
<div data-question-type="multiple_choice_vertical_two_col" data-rq-question-type="multiple_choice_vertical_two_col" class="question-container
">
<div id="question-field-127560470" data-qnumber="10" data-qdispnumber="10" data-question-id="127560470" class=" question-multiple-choice qn question vertical_two_col">
<h3 class="screenreader-only">Question Title</h3>
<fieldset class=" question-fieldset">
<legend class="question-legend">
<h4 id="question-title-127560470" class="
question-title-container ">
<span class="required-asterisk notranslate"> * </span>
<span class="question-number notranslate"> 10<span class="question-dot">.</span>
</span>
<span class="user-generated notranslate
"> And which of the following types of Health Insurance Plans are you considering enrolling in?</span>
</h4>
</legend>
<div class="question-body clearfix notranslate ">
<div class="answer-option-col
answer-option-col-2">
<div class="answer-option-cell
">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="127560470_955517057" name="127560470[]" type="checkbox" class="checkbox-button-input " value="955517057">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="127560470_955517057">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> Medicare Advantage </span>
</label>
</div>
</div>
<div class="answer-option-cell
">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="127560470_955517058" name="127560470[]" type="checkbox" class="checkbox-button-input " value="955517058">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="127560470_955517058">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> Medicare Advantage that includes a Prescription Drug Benefit </span>
</label>
</div>
</div>
<div class="answer-option-cell
">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="127560470_955517059" name="127560470[]" type="checkbox" class="checkbox-button-input " value="955517059">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="127560470_955517059">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> Medicaid </span>
</label>
</div>
</div>
<div class="answer-option-cell
">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="127560470_955517060" name="127560470[]" type="checkbox" class="checkbox-button-input " value="955517060">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="127560470_955517060">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> Original Medicare </span>
</label>
</div>
</div>
</div>
<div class="answer-option-col
answer-option-col-2">
<div class="answer-option-cell
">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="127560470_955517061" name="127560470[]" type="checkbox" class="checkbox-button-input " value="955517061">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="127560470_955517061">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> Dual Special Needs Plan </span>
</label>
</div>
</div>
<div class="answer-option-cell
">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="127560470_955517062" name="127560470[]" type="checkbox" class="checkbox-button-input " value="955517062">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="127560470_955517062">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> Dual Special Needs Plan that includes a Prescription Drug Benefit </span>
</label>
</div>
</div>
<div class="answer-option-cell
">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="127560470_955517063" name="127560470[]" type="checkbox" class="checkbox-button-input " value="955517063">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="127560470_955517063">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> Medicare Supplement Plan </span>
</label>
</div>
</div>
</div>
<div class="other-answer-container other-answer-option-container">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="127560470_955517064" name="127560470[]" type="checkbox" class="checkbox-button-input " value="955517064" data-other-answer="">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="127560470_955517064">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> Other (please specify) </span>
</label>
</div>
<input id="127560470_other" name="127560470_other" type="text" class="text other-answer-text" maxlength="20000" size="50" aria-label="Other (please specify)" data-other-text="">
</div>
</div>
</fieldset>
</div>
</div>
<button id="127560470-ok" class="new-button ok-button user-generated notranslate hide" type="submit"> OK </button>
</div>
<div class="question-click-shield" tabindex="-1" style="height: 148px; width: 896px;"></div>
<div class="question-row clearfix overlay
" tabindex="-1">
<div data-question-type="single_choice_vertical" data-rq-question-type="single_choice_vertical" class="question-container
">
<div id="question-field-127560565" data-qnumber="11" data-qdispnumber="11" data-question-id="127560565" class=" question-single-choice-radio qn question vertical">
<h3 class="screenreader-only">Question Title</h3>
<fieldset class=" question-fieldset" data-radio-button-group="">
<legend class="question-legend">
<h4 id="question-title-127560565" class="
question-title-container ">
<span class="required-asterisk notranslate"> * </span>
<span class="question-number notranslate"> 11<span class="question-dot">.</span>
</span>
<span class="user-generated notranslate
"> Did you switch your Medicare Plan last year?</span>
</h4>
</legend>
<div class="question-body clearfix notranslate ">
<div class="">
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-127560565">
<input id="127560565_955517459" aria-labelledby="127560565_955517459_label" name="127560565" type="radio" role="radio" class="radio-button-input " value="955517459" aria-checked="false">
<label data-sm-radio-button-label="" id="127560565_955517459_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="127560565_955517459">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> Yes </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-127560565">
<input id="127560565_955517460" aria-labelledby="127560565_955517460_label" name="127560565" type="radio" role="radio" class="radio-button-input " value="955517460" aria-checked="false">
<label data-sm-radio-button-label="" id="127560565_955517460_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="127560565_955517460">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> No </span>
</label>
</div>
</div>
</div>
</div>
</fieldset>
</div>
</div>
<button id="127560565-ok" class="new-button ok-button user-generated notranslate hide" type="submit"> OK </button>
</div>
<div class="question-click-shield" tabindex="-1" style="height: 148px; width: 896px;"></div>
<div class="question-row clearfix overlay
" tabindex="-1">
<div data-question-type="single_choice_vertical" data-rq-question-type="single_choice_vertical" class="question-container
">
<div id="question-field-127560606" data-qnumber="12" data-qdispnumber="12" data-question-id="127560606" class=" question-single-choice-radio qn question vertical">
<h3 class="screenreader-only">Question Title</h3>
<fieldset class=" question-fieldset" data-radio-button-group="">
<legend class="question-legend">
<h4 id="question-title-127560606" class="
question-title-container ">
<span class="required-asterisk notranslate"> * </span>
<span class="question-number notranslate"> 12<span class="question-dot">.</span>
</span>
<span class="user-generated notranslate
"> Do you have plans to switch your Medicare health plan in the coming months?</span>
</h4>
</legend>
<div class="question-body clearfix notranslate ">
<div class="">
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-127560606">
<input id="127560606_955517759" aria-labelledby="127560606_955517759_label" name="127560606" type="radio" role="radio" class="radio-button-input " value="955517759" aria-checked="false">
<label data-sm-radio-button-label="" id="127560606_955517759_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="127560606_955517759">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> Yes </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-127560606">
<input id="127560606_955517760" aria-labelledby="127560606_955517760_label" name="127560606" type="radio" role="radio" class="radio-button-input " value="955517760" aria-checked="false">
<label data-sm-radio-button-label="" id="127560606_955517760_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="127560606_955517760">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> No </span>
</label>
</div>
</div>
</div>
</div>
</fieldset>
</div>
</div>
<button id="127560606-ok" class="new-button ok-button user-generated notranslate hide" type="submit"> OK </button>
</div>
<div class="question-click-shield" tabindex="-1" style="height: 335px; width: 896px;"></div>
<div class="question-row clearfix overlay
" tabindex="-1">
<div data-question-type="single_choice_vertical" data-rq-question-type="single_choice_vertical" class="question-container
">
<div id="question-field-127560700" data-qnumber="13" data-qdispnumber="13" data-question-id="127560700" class=" question-single-choice-radio qn question vertical">
<h3 class="screenreader-only">Question Title</h3>
<fieldset class=" question-fieldset" data-radio-button-group="">
<legend class="question-legend">
<h4 id="question-title-127560700" class="
question-title-container ">
<span class="required-asterisk notranslate"> * </span>
<span class="question-number notranslate"> 13<span class="question-dot">.</span>
</span>
<span class="user-generated notranslate
"> Which Medicare Health insurance provider are you currently enrolled with as a member?</span>
</h4>
</legend>
<div class="question-body clearfix notranslate ">
<div class="">
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-127560700">
<input id="127560700_955518419" aria-labelledby="127560700_955518419_label" name="127560700" type="radio" role="radio" class="radio-button-input " value="955518419" aria-checked="false">
<label data-sm-radio-button-label="" id="127560700_955518419_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="127560700_955518419">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> Aetna Medicare </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-127560700">
<input id="127560700_955518420" aria-labelledby="127560700_955518420_label" name="127560700" type="radio" role="radio" class="radio-button-input " value="955518420" aria-checked="false">
<label data-sm-radio-button-label="" id="127560700_955518420_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="127560700_955518420">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> UnitedHealthcare </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-127560700">
<input id="127560700_955518421" aria-labelledby="127560700_955518421_label" name="127560700" type="radio" role="radio" class="radio-button-input " value="955518421" aria-checked="false">
<label data-sm-radio-button-label="" id="127560700_955518421_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="127560700_955518421">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> Cigna </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-127560700">
<input id="127560700_955518422" aria-labelledby="127560700_955518422_label" name="127560700" type="radio" role="radio" class="radio-button-input " value="955518422" aria-checked="false">
<label data-sm-radio-button-label="" id="127560700_955518422_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="127560700_955518422">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> Humana </span>
</label>
</div>
</div>
</div>
<div class="other-answer-container other-answer-option-container">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-127560700">
<input id="127560700_955518423" aria-labelledby="127560700_955518423_label" name="127560700" type="radio" role="radio" class="radio-button-input " value="955518423" aria-checked="false" data-other-answer="">
<label data-sm-radio-button-label="" id="127560700_955518423_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="127560700_955518423">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> Other (please specify) </span>
</label>
</div>
<input id="127560700_other" name="127560700_other" type="text" class="text other-answer-text" maxlength="20000" size="50" aria-label="Other (please specify)" data-other-text="">
</div>
</div>
</fieldset>
</div>
</div>
<button id="127560700-ok" class="new-button ok-button user-generated notranslate hide" type="submit"> OK </button>
</div>
<div class="question-click-shield" tabindex="-1" style="height: 287px; width: 896px;"></div>
<div class="question-row clearfix overlay
" tabindex="-1">
<div data-question-type="multiple_choice_vertical_two_col" data-rq-question-type="multiple_choice_vertical_two_col" class="question-container
">
<div id="question-field-127560764" data-qnumber="14" data-qdispnumber="14" data-question-id="127560764" class=" question-multiple-choice qn question vertical_two_col">
<h3 class="screenreader-only">Question Title</h3>
<fieldset class=" question-fieldset">
<legend class="question-legend">
<h4 id="question-title-127560764" class="
question-title-container ">
<span class="required-asterisk notranslate"> * </span>
<span class="question-number notranslate"> 14<span class="question-dot">.</span>
</span>
<span class="user-generated notranslate
"> And which of the following types of Health Insurance Plans do you currently have?</span>
</h4>
</legend>
<div class="question-body clearfix notranslate ">
<div class="answer-option-col
answer-option-col-2">
<div class="answer-option-cell
">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="127560764_955518793" name="127560764[]" type="checkbox" class="checkbox-button-input " value="955518793">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="127560764_955518793">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> Medicare Advantage </span>
</label>
</div>
</div>
<div class="answer-option-cell
">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="127560764_955518794" name="127560764[]" type="checkbox" class="checkbox-button-input " value="955518794">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="127560764_955518794">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> Medicaid </span>
</label>
</div>
</div>
<div class="answer-option-cell
">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="127560764_955518795" name="127560764[]" type="checkbox" class="checkbox-button-input " value="955518795">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="127560764_955518795">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> Original Medicare </span>
</label>
</div>
</div>
</div>
<div class="answer-option-col
answer-option-col-2">
<div class="answer-option-cell
">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="127560764_955518796" name="127560764[]" type="checkbox" class="checkbox-button-input " value="955518796">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="127560764_955518796">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> Dual Special Needs Plan </span>
</label>
</div>
</div>
<div class="answer-option-cell
">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="127560764_955518797" name="127560764[]" type="checkbox" class="checkbox-button-input " value="955518797">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="127560764_955518797">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> Medicare Supplement Plan </span>
</label>
</div>
</div>
</div>
<div class="other-answer-container other-answer-option-container">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="127560764_955518798" name="127560764[]" type="checkbox" class="checkbox-button-input " value="955518798" data-other-answer="">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="127560764_955518798">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> Other (please specify) </span>
</label>
</div>
<input id="127560764_other" name="127560764_other" type="text" class="text other-answer-text" maxlength="20000" size="50" aria-label="Other (please specify)" data-other-text="">
</div>
</div>
</fieldset>
</div>
</div>
<button id="127560764-ok" class="new-button ok-button user-generated notranslate hide" type="submit"> OK </button>
</div>
<div class="question-click-shield" tabindex="-1" style="height: 269px; width: 896px;"></div>
<div class="question-row clearfix overlay
" tabindex="-1">
<div data-question-type="single_choice_vertical" data-rq-question-type="single_choice_vertical" class="question-container
">
<div id="question-field-127560797" data-qnumber="15" data-qdispnumber="15" data-question-id="127560797" class=" question-single-choice-radio qn question vertical">
<h3 class="screenreader-only">Question Title</h3>
<fieldset class=" question-fieldset" data-radio-button-group="">
<legend class="question-legend">
<h4 id="question-title-127560797" class="
question-title-container ">
<span class="required-asterisk notranslate"> * </span>
<span class="question-number notranslate"> 15<span class="question-dot">.</span>
</span>
<span class="user-generated notranslate
"> Which of the following best describes how you typically shop for Plans on the Medicare website?<br><br></span>
</h4>
</legend>
<div class="question-body clearfix notranslate ">
<div class="">
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-127560797">
<input id="127560797_955518958" aria-labelledby="127560797_955518958_label" name="127560797" type="radio" role="radio" class="radio-button-input " value="955518958" aria-checked="false">
<label data-sm-radio-button-label="" id="127560797_955518958_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="127560797_955518958">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> I use a mobile phone </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-127560797">
<input id="127560797_955518959" aria-labelledby="127560797_955518959_label" name="127560797" type="radio" role="radio" class="radio-button-input " value="955518959" aria-checked="false">
<label data-sm-radio-button-label="" id="127560797_955518959_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="127560797_955518959">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> I use a desktop computer </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-127560797">
<input id="127560797_955518960" aria-labelledby="127560797_955518960_label" name="127560797" type="radio" role="radio" class="radio-button-input " value="955518960" aria-checked="false">
<label data-sm-radio-button-label="" id="127560797_955518960_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="127560797_955518960">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> I use both a mobile phone and desktop computer </span>
</label>
</div>
</div>
</div>
<div class="nota-row-container ">
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-127560797">
<input id="127560797_955518961" aria-labelledby="127560797_955518961_label" name="127560797" type="radio" role="radio" class="radio-button-input " value="955518961" aria-checked="false">
<label data-sm-radio-button-label="" id="127560797_955518961_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="127560797_955518961">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> None of the above </span>
</label>
</div>
</div>
</div>
</div>
</fieldset>
</div>
</div>
<button id="127560797-ok" class="new-button ok-button user-generated notranslate hide" type="submit"> OK </button>
</div>
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<div class="question-row clearfix overlay
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<div data-question-type="multiple_choice_vertical_two_col" data-rq-question-type="multiple_choice_vertical_two_col" class="question-container
">
<div id="question-field-127560835" data-qnumber="16" data-qdispnumber="16" data-question-id="127560835" class=" question-multiple-choice qn question vertical_two_col">
<h3 class="screenreader-only">Question Title</h3>
<fieldset class=" question-fieldset">
<legend class="question-legend">
<h4 id="question-title-127560835" class="
question-title-container ">
<span class="required-asterisk notranslate"> * </span>
<span class="question-number notranslate"> 16<span class="question-dot">.</span>
</span>
<span class="user-generated notranslate
"> Which of the following do you identify as…</span>
</h4>
</legend>
<div class="question-body clearfix notranslate ">
<div class="answer-option-col
answer-option-col-2">
<div class="answer-option-cell
">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="127560835_955519179" name="127560835[]" type="checkbox" class="checkbox-button-input " value="955519179">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="127560835_955519179">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> White </span>
</label>
</div>
</div>
<div class="answer-option-cell
">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="127560835_955519180" name="127560835[]" type="checkbox" class="checkbox-button-input " value="955519180">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="127560835_955519180">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> South Asian (e.g., East Indian, Pakistani, Sri Lankan, etc.) </span>
</label>
</div>
</div>
<div class="answer-option-cell
">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="127560835_955519181" name="127560835[]" type="checkbox" class="checkbox-button-input " value="955519181">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="127560835_955519181">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> Chinese </span>
</label>
</div>
</div>
<div class="answer-option-cell
">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="127560835_955519182" name="127560835[]" type="checkbox" class="checkbox-button-input " value="955519182">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="127560835_955519182">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> Black </span>
</label>
</div>
</div>
<div class="answer-option-cell
">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="127560835_955519183" name="127560835[]" type="checkbox" class="checkbox-button-input " value="955519183">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="127560835_955519183">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> Filipino </span>
</label>
</div>
</div>
<div class="answer-option-cell
">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="127560835_955519184" name="127560835[]" type="checkbox" class="checkbox-button-input " value="955519184">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="127560835_955519184">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> Latin American </span>
</label>
</div>
</div>
</div>
<div class="answer-option-col
answer-option-col-2">
<div class="answer-option-cell
">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="127560835_955519185" name="127560835[]" type="checkbox" class="checkbox-button-input " value="955519185">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="127560835_955519185">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> Arab </span>
</label>
</div>
</div>
<div class="answer-option-cell
">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="127560835_955519186" name="127560835[]" type="checkbox" class="checkbox-button-input " value="955519186">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="127560835_955519186">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> Southeast Asian (e.g., Vietnamese, Cambodian, Laotian, Thai, etc.) </span>
</label>
</div>
</div>
<div class="answer-option-cell
">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="127560835_955519187" name="127560835[]" type="checkbox" class="checkbox-button-input " value="955519187">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="127560835_955519187">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> West Asian (e.g., Iranian, Afghan, etc.) </span>
</label>
</div>
</div>
<div class="answer-option-cell
">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="127560835_955519188" name="127560835[]" type="checkbox" class="checkbox-button-input " value="955519188">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="127560835_955519188">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> Korean </span>
</label>
</div>
</div>
<div class="answer-option-cell
">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="127560835_955519189" name="127560835[]" type="checkbox" class="checkbox-button-input " value="955519189">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="127560835_955519189">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> Japanese </span>
</label>
</div>
</div>
</div>
<div class="other-answer-container other-answer-option-container">
<div data-sm-checkbox="" class="checkbox-button-container ">
<input id="127560835_955519190" name="127560835[]" type="checkbox" class="checkbox-button-input " value="955519190" data-other-answer="">
<label class="answer-label checkbox-button-label no-touch touch-sensitive clearfix" for="127560835_955519190">
<span class="checkbox-button-display ">
</span>
<span class="checkbox-button-label-text question-body-font-theme user-generated "> Other (please specify) </span>
</label>
</div>
<input id="127560835_other" name="127560835_other" type="text" class="text other-answer-text" maxlength="20000" size="50" aria-label="Other (please specify)" data-other-text="">
</div>
</div>
</fieldset>
</div>
</div>
<button id="127560835-ok" class="new-button ok-button user-generated notranslate hide" type="submit"> OK </button>
</div>
<div class="question-click-shield" tabindex="-1" style="height: 196px; width: 896px;"></div>
<div class="question-row clearfix overlay
" tabindex="-1">
<div data-question-type="single_choice_vertical_two_col" data-rq-question-type="single_choice_vertical_two_col" class="question-container
">
<div id="question-field-127560905" data-qnumber="17" data-qdispnumber="17" data-question-id="127560905" class=" question-single-choice-radio qn question vertical_two_col">
<h3 class="screenreader-only">Question Title</h3>
<fieldset class=" question-fieldset" data-radio-button-group="">
<legend class="question-legend">
<h4 id="question-title-127560905" class="
question-title-container ">
<span class="required-asterisk notranslate"> * </span>
<span class="question-number notranslate"> 17<span class="question-dot">.</span>
</span>
<span class="user-generated notranslate
"> What is your marital status?</span>
</h4>
</legend>
<div class="question-body clearfix notranslate ">
<div class="answer-option-col
answer-option-col-2">
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-127560905">
<input id="127560905_955519544" aria-labelledby="127560905_955519544_label" name="127560905" type="radio" role="radio" class="radio-button-input " value="955519544" aria-checked="false">
<label data-sm-radio-button-label="" id="127560905_955519544_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="127560905_955519544">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> Married/Common-Law </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-127560905">
<input id="127560905_955519545" aria-labelledby="127560905_955519545_label" name="127560905" type="radio" role="radio" class="radio-button-input " value="955519545" aria-checked="false">
<label data-sm-radio-button-label="" id="127560905_955519545_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="127560905_955519545">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> Single </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-127560905">
<input id="127560905_955519546" aria-labelledby="127560905_955519546_label" name="127560905" type="radio" role="radio" class="radio-button-input " value="955519546" aria-checked="false">
<label data-sm-radio-button-label="" id="127560905_955519546_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="127560905_955519546">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> Widowed </span>
</label>
</div>
</div>
</div>
<div class="answer-option-col
answer-option-col-2">
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-127560905">
<input id="127560905_955519547" aria-labelledby="127560905_955519547_label" name="127560905" type="radio" role="radio" class="radio-button-input " value="955519547" aria-checked="false">
<label data-sm-radio-button-label="" id="127560905_955519547_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="127560905_955519547">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> Separated </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-127560905">
<input id="127560905_955519548" aria-labelledby="127560905_955519548_label" name="127560905" type="radio" role="radio" class="radio-button-input " value="955519548" aria-checked="false">
<label data-sm-radio-button-label="" id="127560905_955519548_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="127560905_955519548">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> Divorced </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-127560905">
<input id="127560905_955519549" aria-labelledby="127560905_955519549_label" name="127560905" type="radio" role="radio" class="radio-button-input " value="955519549" aria-checked="false">
<label data-sm-radio-button-label="" id="127560905_955519549_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="127560905_955519549">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> Rather not say </span>
</label>
</div>
</div>
</div>
</div>
</fieldset>
</div>
</div>
<button id="127560905-ok" class="new-button ok-button user-generated notranslate hide" type="submit"> OK </button>
</div>
<div class="question-click-shield" tabindex="-1" style="height: 244px; width: 896px;"></div>
<div class="question-row clearfix overlay
" tabindex="-1">
<div data-question-type="single_choice_vertical_two_col" data-rq-question-type="single_choice_vertical_two_col" class="question-container
">
<div id="question-field-127561136" data-qnumber="18" data-qdispnumber="18" data-question-id="127561136" class=" question-single-choice-radio qn question vertical_two_col">
<h3 class="screenreader-only">Question Title</h3>
<fieldset class=" question-fieldset" data-radio-button-group="">
<legend class="question-legend">
<h4 id="question-title-127561136" class="
question-title-container ">
<span class="required-asterisk notranslate"> * </span>
<span class="question-number notranslate"> 18<span class="question-dot">.</span>
</span>
<span class="user-generated notranslate
"> Which of the following best describes your current employment status?</span>
</h4>
</legend>
<div class="question-body clearfix notranslate ">
<div class="answer-option-col
answer-option-col-2">
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-127561136">
<input id="127561136_955520744" aria-labelledby="127561136_955520744_label" name="127561136" type="radio" role="radio" class="radio-button-input " value="955520744" aria-checked="false">
<label data-sm-radio-button-label="" id="127561136_955520744_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="127561136_955520744">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> Work full-time </span>
</label>
</div>
</div>
<div class="answer-option-cell">
<div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-127561136">
<input id="127561136_955520745" aria-labelledby="127561136_955520745_label" name="127561136" type="radio" role="radio" class="radio-button-input " value="955520745" aria-checked="false">
<label data-sm-radio-button-label="" id="127561136_955520745_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="127561136_955520745">
<span class="radio-button-display ">
</span>
<span class="radio-button-label-text question-body-font-theme user-generated "> Work part-time </span>
</label>
</div>
</div>
<div class="answer-option-cell">
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</form>Text Content
Screen Reader Mode Icon Check SCREEN READER MODE to make this survey compatible with screen readers. MHNMTD2180 : MEDICARE MOBILE RESEARCH STUDY QUESTION TITLE * 1. MURRAY HILL NATIONAL IS CONDUCTING A STUDY ON MEDICARE AND WOULD LIKE YOU TO PARTICIPATE. IF YOU QUALIFY FOR THIS STUDY, WE ARE OFFERING AN INCENTIVE. PLEASE BE ASSURED THAT WE ARE NOT SELLING ANYTHING AND THE INFORMATION WE GATHER WILL REMAIN CONFIDENTIAL AND BE USED FOR RESEARCH PURPOSES ONLY. WE HAVE A FEW QUESTIONS TO ASK BEFORE PROVIDING MORE DETAILS AND DETERMINING IF YOU QUALIFY TO PARTICIPATE. Name Company Address Address 2 City/Town State/Province Zip/Postal Code Country Email address Phone number OK QUESTION TITLE * 2. DO YOU IDENTIFY AS... Male Female Other (Please specify) Rather not say OK QUESTION TITLE * 3. IN WHICH STATE DO YOU LIVE? OK QUESTION TITLE * 4. WHAT WAS YOUR ANNUAL HOUSEHOLD INCOME (BEFORE TAXES) IN THE PAST YEAR? Under $20,000 $20,000 to $49,999 $50,000 to $79,999 $80,000 to $109,999 $110,000 to $139,999 $140,000 or more OK QUESTION TITLE * 5. DO YOU OWN A MOBILE PHONE? Yes No OK QUESTION TITLE * 6. WHICH OF THE FOLLOWING STATEMENTS BEST DESCRIBES YOUR LEVEL OF COMFORT WITH USING A MOBILE PHONE? I find it easy to use my mobile phone and navigate the various features I sometimes find it challenging to use certain features on my mobile phone I find it challenging to use my mobile phone and often need assistance OK QUESTION TITLE * 7. ARE YOU AWARE OF MEDICARE HEALTH INSURANCE? Yes No OK QUESTION TITLE * 8. WHICH OF THE FOLLOWING STATEMENTS REFLECTS YOUR CURRENT ENROLMENT STATUS WITH REGARD TO MEDICARE HEALTH INSURANCE? I am currently enrolled in Medicare health insurance I am not currently enrolled in Medicare health insurance, but I am planning to enroll soon I am not enrolled in Medicare health insurance, and I have no plans to enroll in the near future OK QUESTION TITLE * 9. WHICH OF THE FOLLOWING MEDICARE HEALTH INSURANCE PROVIDERS ARE YOU CONSIDERING ENROLLING WITH? Aetna Medicare UnitedHealthcare Cigna Humana Other (please specify) OK QUESTION TITLE * 10. AND WHICH OF THE FOLLOWING TYPES OF HEALTH INSURANCE PLANS ARE YOU CONSIDERING ENROLLING IN? Medicare Advantage Medicare Advantage that includes a Prescription Drug Benefit Medicaid Original Medicare Dual Special Needs Plan Dual Special Needs Plan that includes a Prescription Drug Benefit Medicare Supplement Plan Other (please specify) OK QUESTION TITLE * 11. DID YOU SWITCH YOUR MEDICARE PLAN LAST YEAR? Yes No OK QUESTION TITLE * 12. DO YOU HAVE PLANS TO SWITCH YOUR MEDICARE HEALTH PLAN IN THE COMING MONTHS? Yes No OK QUESTION TITLE * 13. WHICH MEDICARE HEALTH INSURANCE PROVIDER ARE YOU CURRENTLY ENROLLED WITH AS A MEMBER? Aetna Medicare UnitedHealthcare Cigna Humana Other (please specify) OK QUESTION TITLE * 14. AND WHICH OF THE FOLLOWING TYPES OF HEALTH INSURANCE PLANS DO YOU CURRENTLY HAVE? Medicare Advantage Medicaid Original Medicare Dual Special Needs Plan Medicare Supplement Plan Other (please specify) OK QUESTION TITLE * 15. WHICH OF THE FOLLOWING BEST DESCRIBES HOW YOU TYPICALLY SHOP FOR PLANS ON THE MEDICARE WEBSITE? I use a mobile phone I use a desktop computer I use both a mobile phone and desktop computer None of the above OK QUESTION TITLE * 16. WHICH OF THE FOLLOWING DO YOU IDENTIFY AS… White South Asian (e.g., East Indian, Pakistani, Sri Lankan, etc.) Chinese Black Filipino Latin American Arab Southeast Asian (e.g., Vietnamese, Cambodian, Laotian, Thai, etc.) West Asian (e.g., Iranian, Afghan, etc.) Korean Japanese Other (please specify) OK QUESTION TITLE * 17. WHAT IS YOUR MARITAL STATUS? Married/Common-Law Single Widowed Separated Divorced Rather not say OK QUESTION TITLE * 18. WHICH OF THE FOLLOWING BEST DESCRIBES YOUR CURRENT EMPLOYMENT STATUS? Work full-time Work part-time Student Homemaker Maternity leave Retired Unemployed Rather not say OK QUESTION TITLE * 19. CAN YOU TELL ME YOUR AGE? OK DONE Powered by See how easy it is to create a survey. Privacy & Cookie Notice 0 of 19 answered Javascript is required for this site to function, please enable.