Exit this survey HEPATITIS C NATIONAL 1. Question Title 1. Please complete the contact information below. First and Last Name: Address: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: Email Address: Phone Number: Question Title 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. Question Title 3. What is your gender? Male Female Question Title 4. What type of health insurance, if any, do you currently have ? Medicaid Medicare only Medicare HMO / Advantage or supplemental plan Health insurance provided through work or union Purchased health insurance coverage through an exchange Veterans Administration/Active Military/ Tri-care, etc No Health insurance Other Not sure Question Title 5. What is your Occupation-Job Title, Company you work for, and Industry? Occupation: Company: Industry: Title: Question Title 6. What is best describes ethnicity ? American Indian / Alaska Native Asian Black/African American Native Hawaiian/Other Pacific Islander Hispanic Caucasian Other Question Title 7. Have you ever served in any branch of the U.S Armed Forces, military Reserves, or National Guard ? Yes, currently serving Yes, served in the past, but now No, never served in the military Question Title 8. Have you ever been diagnosed with any of the following or had a diagnosis confirmed by a physician ? Anchiall Psoriasis Atopic Dermatitis Bipolar disorder Cancer Cirrhosis of the Liver Crohn's Disease (CD) Depression Diabetes Dontiolefiesis Endometriosis Hepatitis A Hepatitis B Hepatitis C Hidradenitis Suppurativa (HS) / Acne Inversa HIV Hydrolinquitis Kidney Disease / Renal Issues Plaque Psoriasis Psoriatic Arthritis Ulcerative Colitis Uterine Fibroids Uveitis Other (please specify) Question Title 9. What year were you born ? Question Title 10. What year were you diagnosed with Hepatitis C? Question Title 11. Please indicate which of the following options best describes you ? I have never received prescribed medications in order to cure the Hep C virus I am not currently receiving prescribed medications to cure the Hepatitis C virus, but have been treated in the past I am not currently receiving prescribed medications to cure C virus but have either been treated in the past and am cured or was cured spontaneously I am currently receiving prescribed medications to cure the Hep C virus Question Title 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 ? Genotype 1a Genotype 1b Genotype 2 Genotype 3 Genotype 4 Genotype 5 Genotype 6 Next
