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.
CONTACT INFO
Please provide the following:
(Required.)
Name
*
Address
*
Apt # if applicable
City/Town
*
State/Province
*
ZIP/Postal Code
*
Email Address
*
Phone Number
*
*
3.
Research companies are particularly interested in knowing if people have some relationship with or knowledge about certain occupations. Think about the job(s) and occupations you and members of your family, close friends and relatives hold. Do any have jobs that are in the following types of companies or have related job titles:
(Required.)
Market research firm or department of a company
A marketing firm or department of a company
Advertising agency or department of a company
Public relations firm
A media company such as radio, newspaper, television, etc.
A graphic or packaging design firm
A restaurant, grocery store, or caterer, or food-related business
A company or store that sells, manufactures, or distributes any food products
A dietician or nutritionist
None of the above
*
4.
What is your employment status?
(Required.)
Full-time
Part-time
Stay at home parent/homemaker
Not employed
*
5.
Please tell me all the occupations, industries and type of businesses you and other adults in the household hold and work in currently.
(Required.)
Self Title:
Self Company name:
Self Industry:
Spouse Title:
Spouse Company name:
Spouse Industry:
Other adult Title:
Other adult Company name:
Other adult Industry:
*
6.
What is your gender?
(Required.)
Male
Female
Non-Binary/Other
*
7.
What is your age range?
(Required.)
18-24
25-34
35-44
45-54
55-64
65+
*
8.
What is your exact age and Date of Birth?
(Required.)
Age:
Date of Birth:
*
9.
For statistical purposes, please tell me which of the following best describes your ethnic background?
(Required.)
White/Caucasian
Black/African-American
Hispanic/Latino
Native American
Middle Eastern
Asian
Asian Indian
Other (please specify)
*
10.
When was the last time you participated in a market research discussion or a one-on-one interview about products or services?
(Required.)
within the past 6 months
6 months - 1 year
Over 1 year
Never
*
11.
What was/were the subject(s) of the discussion(s) in which you have participated?
(Required.)
*
12.
Do you have any children 18 years old or younger living at home full time?
(Required.)
Yes
No
