Focus Group in Peoria, IL December 19th, 2018

Demographics Questionnaire

Please fill out this short survey if you are interested in participating in our upcoming focus groups scheduled for December 19th, 2018. YOU MUST BE A RESIDENT OF PEORIA, TAZEWELL, WOODFORD OR MARSHALL COUNTY, ILLINOIS IN ORDER TO PARTICIPATE. You will only be contacted if you meet the demographic requirements. Your information is strictly confidential and will NOT be shared, distributed or sold to anyone or any business, EVER! Thank you for your interest!

For more information about our company, please visit our website at www.AccurateVerdicts.com.

Question Title

* 1. What is your contact information?

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

County

Email Address

Phone Number

Question Title

* 2. What is your gender?

Female

Male

Other (specify)

Question Title

* 3. What is your age?

17 or younger

18-20

21-29

30-39

40-49

50-59

60 or older

Question Title

* 4. Which of the following best describes your current relationship status?

Married

Widowed

Divorced

Separated

In a domestic partnership or civil union

Single, but cohabiting with a significant other

Single, never married

Question Title

* 5. Which of the following categories best describes your employment status?

Employed, working full-time

Employed, working part-time

Not employed, looking for work

Not employed, NOT looking for work

Retired

Disabled, not able to work

Question Title

* 6. Which of the following best describes your current occupation?

Arts, Design, Entertainment, Sports, and Media Occupations

Food Preparation and Serving Related Occupations

Architecture and Engineering Occupations

Farming, Fishing, and Forestry Occupations

Sales and Related Occupations

Management Occupations

Building and Grounds Cleaning and Maintenance Occupations

Business and Financial Operations Occupations

Personal Care and Service Occupations

Healthcare Practitioners and Technical Occupations

Computer and Mathematical Occupations

Education, Training, and Library Occupations

Protective Service Occupations

Healthcare Support Occupations

Construction and Extraction Occupations

Installation, Maintenance, and Repair Occupations

Life, Physical, and Social Science Occupations

Production Occupations

Office and Administrative Support Occupations

Legal Occupations

Community and Social Service Occupations

Transportation and Materials Moving Occupations

Other (please specify)

Question Title

* 7. What is the highest level of school that you have completed?

Primary school

Some high school, but no diploma

High school diploma (or GED)

Some college, but no degree

2-year college degree

4-year college degree

Graduate-level degree

None of the above

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* 8. Do you have any children under 18?

Yes

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* 9. Do you identify with any of the following religions? (Please select all that apply.)

Protestantism

Catholicism

Christianity

Judaism

Islam

Buddhism

Hinduism

Native American

Inter/Non-denominational

No religion

Other (please specify)

Question Title

* 10. Are you White, Black or African-American, American Indian or Alaskan Native, Asian, Native Hawaiian or other Pacific islander, or some other race?

White

Black or African-American

American Indian or Alaskan Native

Asian

Native Hawaiian or other Pacific Islander

From multiple races

Some other race (please specify)