SurveyMonkey Powered Online Survey

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.By proceeding, you certify that all answers provided in this application are truthful, accurate, and complete to the best of your knowledge. You also confirm that you have completed this application independently, without the assistance of AI tools, chatbots, or other external aids.

Please note: The client reserves the right to disqualify and turn away any participant without compensation if any information provided is found to be untruthful, inaccurate, or generated by AI.

Do you agree with the conditions above?

Yes

No

3.Thanks again for your interest in the Healthcare study! The group will take place in ONLINE for 90 minutes Tuesday, July 14th- Thursday, July 16th If you qualify and participate, you will receive a $175 digital incentive.

Please check off which times, if any, you'd be available. If you qualify and we have a spot for you we will be in touch!

Please keep in mind checking off times does NOT mean you are recruited for the project; you MUST be contacted by a recruiter.

4.CONTACT INFO Please provide the following:(Required.)

Name

Address

Apt # if applicable

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

6.Which, if any, of the following types of research projects have you participated in, in the past six months? ACCEPT MULTIPLE

Online research survey

Telephone research survey

Online research discussion/focus group*

Product test (either at home or at a mall)

In-person focus group*

I have never participated in any of these types of research projects

8.How do you describe your gender?

Woman

Man

Non-binary/Gender Non-Conforming

Prefer to self-describe (please specify)

10.What is your age and date of birth?

Age

DOB

11.Are you Hispanic, Latina, Latino, Latine, or Latinx?

Yes

No