*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:
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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 identity?(Required.)

Male

Female

Other/ Non-Binary

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

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)

*5.What is your age range?(Required.)

18-29

30-40

41-50

51-60

61+

*6.What is your exact age and Date of Birth?(Required.)

Age:

DOB:

*7.Do you have a child between the ages of 12-15?(Required.)

Yes

No