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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.
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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3.
Where in the country do you live?
(Required.)
Southern CA
Northern CA
West outside of CA
Illinois
Midwest outside of Illinois
South
East
Northeast
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4.
Which of the following best describes your gender?
(Required.)
Male
Female
Non-Binary/Other
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5.
Which of the following would you say best describes you (or your child’s) racial or ethnic background?
(Required.)
Asian or Asian American
Black or African American
Caucasian/White
Native American/American Indian/Alaska Native
Pacific Islander or native Hawaiian
Middle Eastern or Northern African
Hispanic/Latino/a/x
Other (please specify)
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6.
What is your current age range?
(Required.)
15 and under
16-20
21-24
25-34
35-45
46 or over
7.
What is your exact age and Date of Birth?
Age:
DOB:
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8.
Do you have a child age 16-17?
(Required.)
Yes
No
