$120 Survey

We have a SUPER interesting study taking place on Friday, November 16th in NYC. In exchange for (60) minutes of your time - we will pay you $120 CASH for your time.

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* 1. Contact Info

Name

Phone

E-Mail

City, State You Live

Zip Code You Live In

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* 2. During the session you will wear a small cap (similar to a shower cap) that measures brain activity or “brain waves”. The caps do not generate any electricity, are completely safe and have no effect on the wearer. During the session, you will view the TV program through a set of glasses (similar to virtual reality goggles). While viewing the program, you will also see a flickering white light on either side of the screen that is generated by the glasses. If you wear glasses, this is not a problem as the “goggles” can be worn over the top / in front of your glasses. But if you suffer from migraines, epilepsy or other neurological disorder, just to be safe it is not recommended that you participate. Do you understand and agree to participate?

Yes

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* 3. Gender

Male

Female

Third Gender/Non-Binary

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* 4. For statistical purposes ONLY, what is your current household income? (PLEASE NOTE - THIS WOULD BE EVERYONE IN THE HOUSEHOLD - SPOUSE, ROOMATES, ETC.)

a. Less than $25,000

b. $25,000 to less than $50,000

c. $50,000 to less than $75,000

d. $75,000 to less than $100,000

e. $100,000 to less than $125,000

f. $125,000+

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* 5. Where do you currently reside?

a. Manhattan

b. Brooklyn

c. Bronx

d. Queens

e. Staten Island

f. New York (outside of the 5 boroughs)

g. Connecticut

h. New Jersey

Other (please specify)

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* 6. Where are you from a weight standpoint?

I am happy with my current weight

I want to gain weight

I want to loose weight - anywhere from 5-15 pounds

I want to loose weight - anywhere from 16-24 pounds

I want to loose weight - 25+ pounds

I dont know