Survey

This confidential profile sheet will help us in selecting you for future research participation.

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1. Your name .....

Your name ..... First
Last

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2. The YEAR you were born ......

The YEAR you were born ......

3. The best Phone Number to reach you (please include area code).....

The best Phone Number to reach you (please include area code)..... Phone Number:

4. The best time to call you.....

The best time to call you.....

5. Your home ZIP code....

Your home ZIP code.... ZIP:

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6. Have you ever been to us for a research project?

Have you ever been to us for a research project? Within the last year

Within the last five years

More than five years ago

Never

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7. Your current occupation or job? (Please select only one.)

Your current occupation or job? (Please select only one.) Homemaker

Retired

Student

Not Currently Working

Please write-in your occupation or job here

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8. Who is your Health Insurance Carrier? (It should be listed on your Health Insurance Card.)

Who is your Health Insurance Carrier? (It should be listed on your Health Insurance Card.) No Health Insurance

Please List Health Carrier Here

9. What three radio stations do you listen to most often?

What three radio stations do you listen to most often? Station 1
Station 2
Station 3

10. Please give us your e-mail address.

Please give us your e-mail address. Email Address:

Please write the names of others you think might like to come to a research focus group....

11. .....

..... Name
Phone
Age

12. .....

..... Name
Phone
Age

13. .....

..... Name
Phone
Age

14. .....

..... Name
Phone
Age

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*1. Your name .....

*2. The YEAR you were born ......