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1. Please complete the contact information below.

2. Please supply us with a secondary contact number.

Murray Hill Center standard policy requires at least two contact numbers for each respondent.

If the secondary number you give us is not your own number but a friend, family member or co-worker please indicate as such.

3. What is your gender?

4. What type of health insurance, if any, do you currently have ?

5. What is your Occupation-Job Title, Company you work for, and Industry?

6. What is best describes ethnicity ?

7. Have you ever served in any branch of the U.S Armed Forces, military Reserves, or National Guard ?

8. Have you ever been diagnosed with any of the following or had a diagnosis confirmed by a physician ?

9. What year were you born ?

10. What year were you diagnosed with Hepatitis C?

11. Please indicate which of the following options best describes you ?

12. You may or may not be aware that there are six major strains of Hepatitis C virus that cause infection. It's possible to be infected with more than one genotype at a time. Are you aware of the strain you have ?

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