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) City Zip code Phone Email Question Title * 4. In which county is your permanent address? Los Angeles Orange County San Bernardino Ventura Riverside Other (please specify) Question Title * 5. With which gender do you identify? Male Female Non-binary Other (please specify) Question Title * 6. To which age group do you belong? Under 18 18-24 25-35 36-45 Over 45 Question Title * 7. What is your exact age? Question Title * 8. With which ethnicity do you most identify? White Black or African American Hispanic or Latino Asian or Asian American Other (please specify) Question Title * 9. Which of the following best describes your current household situation? Check all that apply Married/partnered/living with significant other Single, live alone Single, live with roommates Single, live with parents Single, live with children Partnered live with parents Partnered live with children Other (please specify) Question Title * 10. Do you have any children ages 2-18 currently living in your home? Yes No Question Title * 11. Which of the following best describes your educational background Some high school High school graduate Trade school graduate Some college/university Undergraduate degree Graduate degree Postgraduate degree Question Title * 12. Which of the following best represents your employment status? Employed full-time Employed part-time Student Unemployed, looking for work Homemaker/stay-at-home parent Retired Question Title * 13. What is your Job Title, Company Name and Industry(if stay at home parent/homemaker -please put partner's info) Job Title Company Name Industry Question Title * 14. Have you or has anyone in your immediate family ever worked in the following fields? Check all that apply An advertising/public relations or marketing company A market research company As a graphics artist, visual artist or at a design agency A newspaper, magazine, radio or television station, blog site, social media A recipe tester A dietician or nutritionist A food blogger Professional chef, caterer, or personal chef Vegetable farmer, wholesaler or retailer A manufacturer, wholesaler, distributor, or retailer of food products or beverages A personal shopper or food delivery person for UberEats or InstaCart or similar service None of the above Question Title * 15. Within which of the following ranges does your current annual total household income fall? Less than $60,000 At least $60,000 but less than $75,000 At least $75,000 but less than $100,000 At least $100,000 but less than $125,000 At least $125,000 but less than $150,000 At least $150,000 + Question Title * 16. When was the last time you participated in a market research project, whether a focus group, one-on-one interview, mystery/secret shopping, online, or otherwise? Within the past 6 months More than 6 months ago Never Question Title * 17. What was the topic, and when was the project? Topic Date Question Title * 18. Are you… (Check all that apply) Allergic to any foods e.g., dairy, nuts, soy Vegan Pre-Diabetic or Diabetic Lactose intolerant/lactose sensitive On a medically restricted diet prescribed by a doctor or nutritionist for example: bariatric/gastric surgery restricted diet, cholesterol restricted diet, sodium restricted Low Carb Gluten Free Vegetarian None of the above Next
