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Hello:
You are invited to participate in our survey [Project Description Here]. In this survey, approximately [Approximate Respondents] people will be asked to complete a survey that asks questions about [General Survey Process]. It will take approximately [Approximate Time] minutes to complete the questionnaire.
Your participation in this study is completely voluntary. There are no foreseeable risks associated with this project. However, if you feel uncomfortable answering any questions, you can withdraw from the survey at any point. It is very important for us to learn your opinions.
Your survey responses will be stricly confidential and data from this research will be reported only in the aggregate. Your information will be coded and will remain confidential. If you have questions at any time about the survey or the procedures, you may contact [Name of Survey Researcher] at [Phone Number] or by email at the email address specified below.
Thank you very much for your time and support. Please start with the survey now by clicking on the Continue button below.
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| What is your approximate age? |
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| Indicate your marital status. |
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| Please indicate your approximate yearly household income before taxes. (Include total income of all adults living in your household.) |
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What was the last grade you completed in school?
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| Please indicate the number of children in your household under the age of 18. |
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| Including yourself, how many persons are in your household? |
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| What is your current work status? |
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| What is the present occupation of the head of household? |
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| Please write in your ZIP Code. | | |
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Tell us how often you visit our site.
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When you visit the site, are you using the computer from
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| Please tell us why you visit our site (please check all that apply)? |
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How much effort did you have to take to find our web site?
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| From what you have seen and your experience with other sites, please rate the following features of the web page:
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From your experience, what do you find to be the biggest challenge with using our site?
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Did the menu of items on the home page make sense to you?
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How did you hear about the Website?
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| We would like to hear your suggestions on how we can expand or improve our site. What additional information or features would you like to see added to the site? | | | | Email | | |
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| In general, do you feel that gasoline prices are: |
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| What is the most important reason for purchasing premium grade gasoline? |
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| When you need to purchase gasoline, do you most often purchase it: |
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| Think about the gasoline station you go to most often. Is it closer to |
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Again think about the gas station you go to most often. What are some reasons this gas station is your favorite? (Check all that apply)
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In an average month, about how much does your total household spend on gasoline?
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| Do you have a gasoline card? |
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| About what part of the amount you pay for gasoline is spent using |
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What are the three best features you would expect to get with a gasoline card?
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| Approximately how many times did you shop for electronic products in the past year? | | |
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Please indicate the approximate total amount your family spent on electronic product within the last year.
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During the past year, have you or a member of your family purchased a major home electronic product?
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| If yes, what item was purchased? (Check all that apply.) |
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| How much did you pay for the item(s)? | | |
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| How many brands or individual models did you examine in the different retail stores? | | |
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Which of the following have you purchased within the last year? (Check all that apply)
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pick only one answer please
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| * how often do you and/or your family go to a restaurant for a meal? |
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| choose as many as apply please
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| * which of the following apply to you? |
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| * how far would you be prepared to travel to get to a good restaurant? |
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| which social status do you fall into? |
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| Below is a list of statements. Please indicate how you feel about each statement by indicating your degree of agreement or disagreement with each statement.
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What is your idea of a good night out?
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| Which of these would be your ideal holiday? |
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This is the questionnaire that deals with health care and your involvement in health care. Please take a few minutes to express your opinions about the availability and quality of health care in your community. Your answers are important to the success of this study.
Thank you for your assistance. |
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| Which community (or rural area) do you live? | | |
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| Is there a wide difference in performance between the available hospitals in this area? |
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| Do you have a favorite hospital? |
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| Is there a wide difference in the cost of the different hospitals in this area? |
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| How many years have you lived in this community? | | |
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| How satisfied are you with the skill and competency of the staff? |
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| Does the hospital have equipment for modern diagnosis and treatment? |
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How satisfied are you with the following:
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| Overall cleanliness of the hospital |
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| Friendliness and courtesy of the staff |
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| Convenience of location for you |
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| What kind of medical insurance coverage do you have? |
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| How many times have you and any member of your family been to your doctor in the last year? | | |
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| Which source of care would you prefer if you had a personal injury that could be handled equally well by each of these sources of health care: |
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| If you or a member of your family have received medical care at a hospital that was'nt the hospital in your area, why did you choose the other hospital? |
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Indicate activities/interests which you and/or household members enjoy on a regular basis:
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