Question Title * 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 InfoFinancial Incentive InfoAdler Weiner Privacy Policy 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. Question Title * 2. CONTACT INFO Please provide the following: Name * Address * Apt # if applicable City/Town * State/Province * ZIP/Postal Code * Email Address * Phone Number * Question Title * 3. What is your gender identity? Male Female Other/ Non-Binary Question Title * 4. With which ethnicity do you identify? Check all that apply American Indian or Alaska Native Asian or Asian American Black or African American Hispanic or Latino Middle Eastern or North African Native Hawaiian or other Pacific Islander White Other (please specify) Question Title * 5. What is your age range? 18-29 30-40 41-50 51-60 61+ Question Title * 6. What is your exact age and Date of Birth? Age: DOB: Question Title * 7. Do you have a child between the ages of 12-15? Yes No Next
