Question Title * 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 InfoFinancial Incentive InfoAdler Weiner Privacy Policy 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. Question Title * 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? Yes No Question Title * 3. Please fill in the following NAME FIRST AND LAST COMMUNITY ADDRESS BUILDING NUMBER FLOOR PHONE EMAIL PARKING INSTRUCTIONS Question Title * 4. With which gender do you identify? Male Female Non-binary Other (please specify) Question Title * 5. To which age group do you belong? Under 60 60-75 Over 75 Question Title * 6. What is your exact age? Question Title * 7. What is your current household situation? Single, living alone Living in couple Question Title * 8. Which of the following best describes where you live? I am a tenant of private accommodation in a CCRC (Continuing Care Retirement Community) with onsite dining I am the owner of private accommodation in a CCRC with onsite dining I live in a community that could be described as: a retirement community, a life plan community, independent living, or a community that offers more than one level of care (independent living and/or assisted living and/or memory care and/or skilled nursing) I do not live in a CCRC but might have somebody to refer who does I do not live in a CCRC and do not have anybody to refer who does Other (please specify) Next
