Small Business Survey on Health Care

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SMALL BUSINESS SURVEY ON HEALTH CARE

Please answer the questions below, and then press send to submit your survey.

	Business name

	Business address

	City

	State

	Phone Number

	E-mail Address

	Web site (optional)

	Your first name

	Your last name


	1. How many people are employed by your business? (check one)
	1 2-5 6-10 11-25 26-50 50+
	2. Are you concerned about health care? (check one)
	Yes No Don't Know
	3. Are the interests of small businesses being recognized in the health care debate? (check one)
	Yes No Don't Know
	4. Do you think the difficulties of getting and paying for health care keep people from starting a small business? (check one)
	Yes No Don't Know
	5. Do you provide health care to your employees? (check one)
	Yes No

	IF YES TO QUESTION 5, PLEASE ANSWER QUESTIONS 6 - 9
	6. Why do you choose to offer coverage to your employees? (check all that apply)
	Attract/retain better employees Responsibility to provide it More productive work-force Other (please indicate below)

	7. Have the health care costs your business pays gone up over the past year? (check one)
	Yes No Don't Know
	8. How predictable are your business’s health care costs? (check one)
	Roughly the same from year to year Vary somewhat Vary a lot Don't know
	9. Have you changed insurers in the past year? (check one)
	Yes No Don't Know

	IF NO TO QUESTION 5, PLEASE ANSWER QUESTIONS 10 - 11
	10. Why do you choose not to offer coverage? (check all that apply)
	Too expensive Not enough employees want it Too complicated/too much paperwork Don't need it to recruit/retain staff Not business’s responsibility Other (please indicate below)

	11. Do wish you could provide health insurance that was affordable to you and your employees? (check one)
	Yes No Don't Know

	12. (optional) Tell us your story. We are interested in hearing more about how the health care issue has affected your business. Your story can help us illustrate problems small businesses may face with health care. If you have a particular story to tell, please share it below.

	May we use your story on our website and in our media work? (check one)
	Yes No
	Do you have a photo to share of you in front of your business?
	If YES, please check this box and e-mail your photo to media@pirg.org
	Thank you for your participation in our survey.

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ISSUES

SMALL BUSINESS SURVEY ON HEALTH CARE

Please answer the questions below, and then press send to submit your survey.

Business name

Business address

City

State

Phone Number

E-mail Address

Web site (optional)

Your first name

Your last name

1. How many people are employed by your business? (check one)

2. Are you concerned about health care? (check one)

3. Are the interests of small businesses being recognized in the health care debate? (check one)

4. Do you think the difficulties of getting and paying for health care keep people from starting a small business? (check one)

5. Do you provide health care to your employees? (check one)

IF YES TO QUESTION 5, PLEASE ANSWER QUESTIONS 6 - 9

6. Why do you choose to offer coverage to your employees? (check all that apply)

7. Have the health care costs your business pays gone up over the past year? (check one)

8. How predictable are your business’s health care costs? (check one)

9. Have you changed insurers in the past year? (check one)

IF NO TO QUESTION 5, PLEASE ANSWER QUESTIONS 10 - 11

10. Why do you choose not to offer coverage? (check all that apply)

11. Do wish you could provide health insurance that was affordable to you and your employees? (check one)

12. (optional) Tell us your story.We are interested in hearing more about how the health care issue has affected your business. Your story can help us illustrate problems small businesses may face with health care. If you have a particular story to tell, please share it below.

May we use your story on our website and in our media work? (check one)

Do you have a photo to share of you in front of your business?

Thank you for your participation in our survey.

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12. (optional) Tell us your story.

We are interested in hearing more about how the health care issue has affected your business. Your story can help us illustrate problems small businesses may face with health care.

If you have a particular story to tell, please share it below.