<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><html lang="en-US"><head><script LANGUAGE="JavaScript" src="siam/surveylanding/noenter-min.js?x=3" charset="utf-8" type="text/javascript"></script><script language="JavaScript" type="text/javascript">function keepAlive(){var i=new Image();var d=new Date();i.src="siam/surveylanding/alive.asp?sid=746D70337270366763313336393033303130322E3037&d="+d.valueOf();}setInterval("keepAlive()",1800000);</script><meta name="GENERATOR" content="snap10 - pda3 questionnaire export"><meta http-equiv="Content-Type" content="text/html; charset=utf-8"><meta name="HandheldFriendly" content="true"><meta name="viewport" content="width=device-width, minimum-scale=0.25, initial-scale=1.0, maximum-scale=4.0"><title>&nbsp;</title><link type='text/css' charset='utf-8' rel='stylesheet' href='http://surveys.dhs.state.mn.us/k/133416827352/ownyourfuturedemo.css'><script language='javascript' type='text/javascript'>document.write("<style type='text/css'>form{display:none;}<"+"/style>");</script><script LANGUAGE="JavaScript" src='http://surveys.dhs.state.mn.us/k/133416827352/SnapScriptVariables.js' charset='utf-8' type='text/javascript'></script>
</head><body  onload="oL()"><script language='javascript' type='text/javascript'>document.write("<p id='snapIntro'>Please wait while the survey loads...<"+"/p>");</script><form action="siam/surveylanding/interviewer.asp" method="post" id="SnapForm"><input type="image" id="submit" src="images/1x1.gif" style="width:0%;height:0%;"><input type="hidden" id="SnapSession" name="SnapSession" value="746D70337270366763313336393033303130322E3037"><input type="hidden" id="SurveyKey" name="SurveyKey" value="133416827352"><input type="hidden" id="Enter" name="Enter" value=""><input type="hidden" id="PAGE" name="PAGE" value="1"><table  width='100%' ><tr><td colspan='3' style='height:0.5em;'></td></tr><tr><td style='width:3.0em;'>&nbsp;</td><td><a href="siam/surveylanding/interviewer.asp?sid=746D70337270366763313336393033303130322E3037&amp;ta=ownyourfuturedemo_t.msf" accesskey="l" title="Link to text only (alt+l)">text only</a><table class="V2_classT" style="width:100%;" summary="" id="V2"><tr><td class="question_1"><img src="http://surveys.dhs.state.mn.us/k/133416827352/own-your-future-minnesota-logo.jpg" height="80" width="150" alt="Minnesota Own Your Future logo; Choice, control, peace of mind"></td></tr></table><table style="width:100%;" summary="" id="V3_SPACER"><tr><td style="height:18px;"></td></tr></table><table class="V3_classT" style="width:100%;" summary="" id="V3"><tr><td class="question_2" style="width:100%;">Thank you for visiting Minnesota’s Own Your Future web pages. We will provide you with important and easy-to-understand information about how you can maintain your independence and dignity as you age or if you become ill or disabled.<br><br>After you click the Submit button, you will see a thank you and the window will close. If the window does not close and another window appears with the following message, <br> &nbsp; &nbsp; The webpage you are viewing is trying to close the window. <br> &nbsp; &nbsp; Do you want to close this window? Click Yes.<br><br>But first, please take a moment to tell us: &nbsp; </td></tr></table><table style="width:100%;" summary="" id="V4_SPACER"><tr><td colspan="2" style="height:18px;"></td></tr></table><table class="V4_classT" style="width:100%;" summary="" id="V4"><tr><td class="name_1" rowspan="2" style="width:8%;height:100%;"><span class='qnum'><a name="Q1">1.</a></span></td><td class="question_2" style="width:92%;"><label for="V4_1">What is your zip code?</label></td></tr><tr><td class="box_1" style="width:92%;height:2px;"><input type="text" size="10" maxlength="12" id="V4_1" name="V4"></td></tr></table><table style="width:100%;" summary="" id="V5_SPACER"><tr><td colspan="2" style="height:18px;"></td></tr></table><table class="V5_classT" style="width:100%;" summary="" id="V5"><tr><td class="name_1" rowspan="6" style="width:8%;height:100%;"><span class='qnum'><a name="Q2">2.</a></span></td><td class="question_3" style="width:92%;">How did you learn about these web pages?</td></tr><tr><td class="codelabel_1" style="width:92%;height:100%;"><table style="width:100%;height:100%;" summary=""><tr><td class="box_2" style="width:2%;height:2px;"><input type="radio" value="1" id="V5_1" name="V5"></td><td class="codelabel_2" style="width:98%;"><label for="V5_1">Received a letter from the governor</label></td></tr></table></td></tr><tr><td class="codelabel_1" style="width:92%;height:100%;"><table style="width:100%;height:100%;" summary=""><tr><td class="box_2" style="width:2%;height:2px;"><input type="radio" value="2" id="V5_2" name="V5"></td><td class="codelabel_2" style="width:98%;"><label for="V5_2">Saw a notice or ad on the internet</label></td></tr></table></td></tr><tr><td class="codelabel_1" style="width:92%;height:100%;"><table style="width:100%;height:100%;" summary=""><tr><td class="box_2" style="width:2%;height:2px;"><input type="radio" value="3" id="V5_3" name="V5"></td><td class="codelabel_2" style="width:98%;"><label for="V5_3">Searched the internet using Google</label></td></tr></table></td></tr><tr><td class="codelabel_1" style="width:92%;height:100%;"><table style="width:100%;height:100%;" summary=""><tr><td class="box_2" style="width:2%;height:2px;"><input type="radio" value="4" id="V5_4" name="V5"></td><td class="codelabel_2" style="width:98%;"><label for="V5_4">Heard about this word of mouth</label></td></tr></table></td></tr><tr><td class="codelabel_1" style="width:92%;height:100%;"><table style="width:100%;height:100%;" summary=""><tr><td class="box_2" style="width:2%;height:2px;"><input type="radio" value="5" id="V5_5" name="V5"></td><td class="codelabel_2" style="width:98%;"><label for="V5_5">Other</label></td></tr></table></td></tr></table><table style="width:100%;" summary="" id="V8_SPACER"><tr><td colspan="2" style="height:18px;"></td></tr></table><table class="V8_classT" style="width:100%;" summary="" id="V8"><tr><td class="name_2" rowspan="2" style="width:8%;height:100%;">&nbsp;</td><td class="question_2" style="width:92%;"><label for="V8_1">Briefly describe how you learned about the Minnesota Own Your Future web pages.</label></td></tr><tr><td class="box_1" style="width:92%;height:2px;"><textarea rows="3" cols="68" id="V8_1" name="V8"></textarea></td></tr></table><table style="width:100%;" summary="" id="V10_SPACER"><tr><td style="height:18px;"></td></tr></table><table class="V10_classT" style="width:100%;" summary="" id="V10"><tr><td class="question_4" style="width:100%;"><h2 class="question_5">Thank you!</h2></td></tr></table></td><td style='width:3.0em;'>&nbsp;</td></tr><tr><td colspan='3' style='height:3.0em;'></td></tr></table><table id='snapbuttons'  width='100%' ><tr><td  style='text-align:center;'>&nbsp; <input type="image" class='tools_1'src="http://surveys.dhs.state.mn.us/k/133416827352/ownyourfuturedemo_rset.gif" alt="Clear Answers from this Page" name='reset' value="Reset"> <input type="image" class='tools_1'src="http://surveys.dhs.state.mn.us/k/133416827352/ownyourfuturedemo_subm.gif" alt="Submit Your Answers" name='Submit' value="Submit"> &nbsp;</td></tr></table></form>
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