If you are interested in providing your opinions and earning some additional money, you may be interested in joining us for one of our focus groups. If you are interested in participating in one of our focus groups please register. We will be conducting so many focus groups every year so make sure to register ASAP: Note: We will contact you by text message from a 516 number to check for availability so provide a valid cell phone number.

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1. What language do you prefer speaking fluently?
What language do you prefer to participate on Focus Groups?

  Only English Only Spanish Both Spanish and English equally
What language do you prefer speaking fluently?
What language do you prefer to participate on Focus Groups?

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2. What is your first name? 

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3. What is your last name?

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4. Home Phone: *Very Important verify numbers are written correctly*

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5. Cell Phone Number: *Very Important verify numbers are written correctly*

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6. Email: *Very Important verify email is written correctly*

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7. What is your gender?

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8. Your Birth Date: Example: 08/12/1978

Birth Date:

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9. Exact Age:

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10. Home Address:

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11. Home City:

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12. Home State:

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13. Home Zip:

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14. Home County:

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15. Work Zip:

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16. Work County:

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17. Employer:

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18. OccupationTitle:

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19. Please describe your race/ethnicity.

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20. What is the highest level of school that you have completed?

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21. Marital Status:

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22. Are you pregnant?

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23. Are you planning on becoming pregnant someday?

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24. Do you have any children under 18?

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25. Could you please tell me the age range of your children who live with you at home?

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26. Do have a Drivers License?

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27. Do you own a Car?

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28. What is the year, make, and model of your automobile?

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29. Do you suffer from any of the following ailments? (Please select all that apply to you.)

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30. Who is your Cell phone, Internet, Provider/Company?

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31. Please specify Make and Model of your Smartphone: Examples: iPhone 6, Samsung Galaxy s7 edge

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32. Do you currently have health insurance, or not?

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33. IF Yes: Who is your Health Insurance Provider? Read list mark all that apply

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34. Were you born in the U.S.?

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35. ***What is your country of birth? What country of origin is your family from?

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36. Which of the following best describes your current employment status? Read list mark all that apply

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37. What is your approximate average household income?

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38. Now, we would like to know how well you speak, read, write in English and Spanish

  a. Very well b. Well c. A little d. Very little e. Not at all
Would you say you speak English
Would you say you speak Spanish
Would you say you Read English
Would you say you Read Spanish
Would you say you Write English
Would you say you Write Spanish

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39. How would you describe your sexual orientation?

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40. Do you rent or own the place where you live?

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41. How did you hear from us?

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42. What county you live in?

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43. *Very Important Zip Code, County & Country live in:

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44. Which, if any, of the following Social Media, do you use?

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45. Do you smoke cigarettes?

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