Skip to content
*
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.
CONTACT INFO
Please provide the following:
(Required.)
Name
*
Address
*
Apt # if applicable
City/Town
*
State/Province
*
ZIP/Postal Code
*
Email Address
*
Phone Number
*
*
3.
What is your gender?
(Required.)
Male
Female
Non- Binary/Other
*
4.
What is your age?
(Required.)
*
5.
In what age range do you fall?
(Required.)
Under 18
18 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65+
*
6.
In the past 12 months, have you participated in any type of market research study, such as a poll, survey or focus group?
(Required.)
Yes
No
*
7.
If yes, how many times? (if no put 0)
(Required.)
*
8.
What type of research was it and what kinds of issues did it cover? (If none put N/A)
(Required.)
*
9.
Are you a U.S. Citizen?
(Required.)
Yes
No
*
10.
Have you ever been convicted of a felony?
(Required.)
Yes
No
*
11.
Are you registered to vote in California, or do you have a valid California license or state-issued ID?
(Required.)
Yes
No
*
12.
You will be asked to show your state-issued ID at check-in to verify your identity and city residency. Are you able to bring and show your ID on September 22nd?
(Required.)
Yes
No
*
13.
What city or area do you live in? (i.e. Santa Monica, Sherman Oaks, Boyle Heights, etc.)
(Required.)
*
14.
Are you a student?
(Required.)
Yes
No
