UNINSURED SURVEY

1.  Age Group

2. Marital Status
3. Employment Status
4.  Do you currently have health insurance?
5.  If you have health insurance, is it job-based?
6. If you have health insurance that is job based, do you contribute any portion for yourself?Your dependents?
7.  If your insurance is not job based, approximately how much does it cost you per month?
8. If you don't have coverage on you or any of your dependents, why Not?
9. Has the rising cost of health care affected you in any way?

How?

10.  What do you see as the problems facing society today as far as affordable health care?

11.  Do you have any ideas about possible solutions?