First Name:

Last Name:

Email Address:

Phone Number:

Gender: Select One Male Female

1. Are you aware of the debate currently taking place in Washington dealing with reforming our nation's health care system?
   

   Very Aware

   Somewhat Aware

   Generally Not Aware

   No Interest

   Undecided

2. How interested are you in following the debate taking place on health care reform in America?
   

   Very Interested

   Somewhat Interested

   Generally Not Interested

   No Interest

   Undecided

3. Would you be willing to get involved to make your voice heard so that we can improve our nation's health care system?
   

   Very Likely to Get Involved

   Somewhat Likely to Get Involved

   Not Likely to Get Involved

   Would Never Get Involved

   Undecided

4. Would you be willing to attend a town hall meeting or other community forum to discuss ways for Washington to improve health care?
   

   Very Likely to Attend a Town Hall Meeting

   Somewhat Likely to Attend a Town Hall Meeting

   Not Likely to Attend a Town Hall Meeting

   Would Never Attend a Town Hall Meeting

   Undecided

5. In your household, are you the WellPoint subscriber, Spouse or Other?
   

   Subscriber

   Spouse

   Other

   Don't Know

6. As WellPoint works to develop solutions to solve our nation's health care crisis would you like to receive future updates on their efforts?
   

   Would Like to Receive Future Updates

   Would Not Like to Receive Future Updates

All fields are required.