1. Moms with Kids 11-15yrs old

 

*
1. Name

*
2. Gender

3. Work Phone Number

4. Cell Phone Number

*
5. Best contact number between the hours of 9am-7pm

*
6. Age

*
7. Email Address

8. Race

9. What is the highest level of education you have completed?

10. Which of the following income groups best represents your total annual household income?

11. When was the last time you participated in a research focus group or one on one interview?

12. Are you currently scheduled to participate in any market research studies?

13. Are you the female head of your household who is responsible for what your child(ren) eats?

14. Do you or does any member of your household, relatives, or close friends work for...

 YesNo
a marketing company or department
a market research firm or department
an advertising or public relations agency
a company that sells, manufactures, distributes food or is a dietician or nutritionist

15. Please tell me how many children you have living in your household in the folloing catagories.

*
16. Do you or does anyone in your household currently have any food allergies or dietary restrictions, such as lactose intolerance, diabetes or food sensitivities?

*
17. Are you or is anyone in your household a vegetarian or avoids meat for specific medical reasons, religious reasons or because of personal choice?

18. Are you the primary grocery shopper (do half or more of the family grocery shopping)?

19. Thinking about frozen breakfast sandwiches with meat, cheese and eggs and other sandwich like items (such as Hot Pockets/Lean Pockets, Toaster Scrambles) that you heat and eat, which of the following statements best describes how you feel about them?

20. Please tell me which, if any, of the following food brands you DISLIKE and tend to avoid?