*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.FOR IN PERSON RESEARCH:
In order to gain admittance to the facility, you need to bring:

• A Photo ID
• Reading glasses if you need them

Please make sure to self assess your health prior to the session and we ask that you cancel in advance if you are sick with Cold/Flu/Covid-19 symptoms.

Frequently we do not allow cell phones, smart watches, cameras or any electronic/digital devices into the research. There is a possiblity you will be asked to leave your devices with our front desk team where they will be kept securely during the research.

If qualified and based on these participation requirements, are you willing to participate in this in-person interview?(Required.)

Yes

No

*3.Please fill in the following(Required.)

Name (First and last)

Address

City

Zip code

Phone

Email

*4.In which county is your permanent residence?(Required.)

Los Angeles

Orange County

Ventura

San Bernardino

Other (please specify)

*5.With which gender do you identify?(Required.)

Male

Female

Non-binary

Other (please specify)

*6.To which age group do you belong?(Required.)

Under 18

18-24

25-34

35-44

45-54

55-64

65+

*7.What is your exact age?(Required.)

*8.With which ethnicity do you identify? Check all that apply(Required.)

White

Black or African American

Hispanic or Latino

Asian or Asian American

Other (please specify)

*9.Are you currently employed?(Required.)

Yes

No