Thank you for completing this brief survey to determine whether you qualify for our upcoming focus groups. This information is for research and screening purposes only and will be kept confidential. It will not be shared, and you will not receive marketing offers as a result of completing this questionnaire.

If you have previously been in one of our focus groups or you already have filled out this form, we will contact you when we have a group in your area.  There is no need to fill out the form again.

If you have any problems with this survey, please contact

* 1. Please provide contact information so we know how to get in touch with you: