Humana Health Equity Innovation Hub
Digital Transformation Center

As part of the Health Equity Innovation Hub programming, we would like to ask you a few questions about your life experiences.

Your responses will help us capture the demographic, employment, and assistance information of the community we serve.

I want you to know that your responses will be kept confidential. Additionally, you may elect not to answer questions by choosing “prefer not to say” as an answer. We appreciate your participation and look forward to better serving you in the future.

jose.najera@louisville.edu

Please read and answer all questions carefully.

First Name

Middle Name

Last Name

Email Address

Telephone Number

What is your phone number?

Type of telephone service

What time of phone service do you use?

Preferred Method of Contact

What is your preferred method of contact?

How did you hear about our program?

What is your Zip Code?

Gender

What gender do you identify as?

Age

Are you a U.S. citizen?

If you answered no, What country were you born in?

Ethnicity

Please specify your ethnicity.

Language

Which languages are you capable of speaking fluently? (Check all that apply)

Marital Status

Are you married?

Family & Dependents

Subsidies

Which, if any, of these subsidies do you receive?

Education

What is the highest degree or level of education you have completed?

Income

What is your annual household income?

Employment Status

What is your current employment status?

The Humana Health Equity Innovation Hub

Jan 3, 2023

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Humana Health Equity Innovation HubDigital Transformation Center

Humana Health Equity Innovation Hub
Digital Transformation Center