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1.
This survey is being conducted by Adler Weiner Research in order to determine your eligibility for a focus group or interview about which you have been contacted. At no point are your individual answers ever sold or shared with our clients (aggregate data or anonymized summaries of the overall survey information may possibly be shared with our clients, however). This survey serves solely as a means for screening. Once the project has been completed this data will be deleted. For more information please see:
Right to Opt-Out Info
Financial Incentive Info
Adler Weiner Privacy Policy
(Required.)
I consent to Adler Weiner Research collecting, storing and processing my personal information for the purpose of determining my eligibility for this market research focus group or interview.
I understand and consent to the following: That should I be eligible for participation in this market research focus group or interview, my contact information (phone, email, and home address) may be shared with the client for purposes related only to this particular project and are not limited to: screening calls to further determine eligibility, sending of "homework" or pre-session assignments via email, allowing access to an online platform via email, or for in-home interviews conducted at your residence.
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2.
FOR IN PERSON RESEARCH:
In order to gain admittance to the facility, you need to bring:
A Photo ID
Reading glasses if you need them
Please make sure to self assess your health prior to the session and we ask that you cancel in advance if you are sick with Cold/Flu/Covid-19 symptoms.
Frequently we do not allow cell phones, smart watches, cameras or any electronic/digital devices into the research. There is a possiblity you will be asked to leave your devices with our front desk team where they will be kept securely during the research.
If qualified and based on these participation requirements, are you willing to participate in this in-person interview?
(Required.)
Yes
No
3.
This research project will take place In Person in ORANGE COUNTY. Are you willing and able to participate in our Irvine office?
Yes
No
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4.
CONTACT INFO
Please provide the following:
(Required.)
Name
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Address
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Apt # if applicable
City/Town
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State/Province
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ZIP/Postal Code
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Email Address
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Phone Number
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5.
Please indicate your gender below.
(Required.)
Male
Female
Non Binary
Other (please specify)
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6.
What is your age?
(Required.)
Under 25
25-41
42-57
58-70
71+
7.
What is your exact age?
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8.
Which of the following best describes you?
(Required.)
Employed full time
Employed part time
Homemaker
Full time student
Retired
Unemployed
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9.
Which category below includes your total annual household income before taxes?
(Required.)
Less than $25,000
$25,000 - $59,999
$60,000 - $79,999
$80,000 - $89,999
$90,000 - $99,999
$100,000 - $124,999
$125,000 - $149,999
$150,000+
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10.
What is your occupation? If you are retired/unemployed/Homemaker, please list most recent work experience.
(Required.)
Job Title:
Company Name:
Industry:
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11.
Are you of Hispanic, Latino, or Spanish origin?
(Required.)
Yes
No
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12.
What is your race? Select all that apply
(Required.)
Caucasian / White
African American / Black
Asian
American Indian and Alaska Native
Native Hawaiian and Other Pacific Islander
Other (please specify)
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13.
Do you or any member of your household work in any of the following fields?
(Required.)
Marketing research, advertising, or public relations
Newspaper, television, or radio
Market research or consumer research
The manufacture, sale, or distribution of automotive products
The manufacture, sale, or distribution of computers or technology products
The manufacture, sale, or distribution of food or beverage products
None of these
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14.
Which of the following types of beverages have you purchased in the past 3 months?
(Required.)
Wine
Beer
Fruit Juice
Smoothies (fruit and/or vegetable)
Bottled/canned iced tea
Bottled/canned iced coffee
Bottled water
Soda
Hard seltzer
Milk
None of the above
