Skip to content
*
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.
*
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.
Please fill in the following
(Required.)
Name (First and last)
City
Zip code
Phone
Email
*
4.
In which county is your permanent address?
(Required.)
Los Angeles
Orange County
San Bernardino
Ventura
Riverside
Other (please specify)
*
5.
With which gender do you identify?
(Required.)
Male
Female
Non-binary
Other (please specify)
*
6.
To which age group do you belong?
(Required.)
Under 18
18-24
25-35
36-45
Over 45
*
7.
What is your exact age?
(Required.)
*
8.
With which ethnicity do you most identify?
(Required.)
White
Black or African American
Hispanic or Latino
Asian or Asian American
Other (please specify)
*
9.
Which of the following best describes your current household situation? Check all that apply
(Required.)
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)
*
10.
Do you have any children ages 2-18 currently living in your home?
(Required.)
Yes
No
*
11.
Which of the following best describes your educational background
(Required.)
Some high school
High school graduate
Trade school graduate
Some college/university
Undergraduate degree
Graduate degree
Postgraduate degree
*
12.
Which of the following best represents your employment status?
(Required.)
Employed full-time
Employed part-time
Student
Unemployed, looking for work
Homemaker/stay-at-home parent
Retired
*
13.
What is your Job Title, Company Name and Industry(if stay at home parent/homemaker -please put partner's info)
(Required.)
Job Title
Company Name
Industry
*
14.
Have you or has anyone in your immediate family ever worked in the following fields? Check all that apply
(Required.)
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
*
15.
Within which of the following ranges does your current annual total household income fall?
(Required.)
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 +
*
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?
(Required.)
Within the past 6 months
More than 6 months ago
Never
17.
What was the topic, and when was the project?
Topic
Date
*
18.
Are you… (Check all that apply)
(Required.)
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
