Grad Student Health Care Survey

Dear Fellow Graduate Student,

The GSU Quality of Life Committee is in the process of collecting information needed for the improvement of the quality and availability of health care for graduate students and their families. We wish to collect the following information, which will be held in the utmost confidence. Toward this end, we are asking you to respond to the following questions. Your participation is vital to health care negotiations with the university!

Please fill out the form completely.

Last name:
First name:
Key (sent to you in email):
Size of your family: Adults Children
Please indicate any public assistance:
  1. Medicaid
  2. WIC
  3. AFDC
  4. Food Stamps
  5. Other - Please specify ...
If married, is your spouse:
Number of uninsured children:
Where do you live?
University Village
Off Campus
Fischer/O'Hara Grace
Would you utilize a health insurance policy sponsored and subsidized by the university for your spouse and children if it were made available?

Thanks very much for taking the time to respond to this questionnaire. If you have further comments for the GSU on this issue, please either send them to me or directly to the gsu at