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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
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Adler Weiner Privacy Policy
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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.
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2.
CONTACT INFO
Please provide the following:
(Required.)
Name
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Address
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Apt # if applicable
City/Town
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State/Province
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ZIP/Postal Code
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Email Address
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Phone Number
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3.
Are you a resident of Los Angeles County?
(Required.)
Yes
No
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4.
In which part of LA do you live?
(Required.)
Alhambra
Compton
Lynwood
West Hollywood
Altadena
Culver City
Los Angeles City
Hollywood
Arcadia
Glendale
La Canada
Pasadena
Beverly Hills
Huntington Park
Monterey Park
San Gabriel
Burbank
Inglewood
Southgate
Azusa
City of Industry
Diamond Bar
Irwindale
Monrovia
Walnut
Baldwin Park
Claremont
Duarte
La Puente
Pomona
West Covina
Bradbury
Covina
Glendora
La Verne
San Dimas
Agoura Hills
Hidden Hills
Reseda
Van Nuys
Calabasas
Mission Hills
San Fernando
Westlake Village
Chatsworth
Northridge
Sherman Oaks
Encino
Porter Ranch
Tarzana
Bell Gardens
Downey
La Habra Heights
Long Beach
Redondo Beach
Torrance
Bellflower
El Segundo
La Mirada
Manhattan Beach
Rolling Hills
Whittier
Carson
Gardena
Lakewood
Norwalk
San Pedro
Cerritos
Hawthorne
Lawndale
Paramount
Santa Fe Springs
Cudahy
Hermosa Beach
Lomita
Rancho Palos Verdes
Rolling Hills Estates
Brentwood
Malibu
Marina del Rey
Pacific Palisades
Playa del Rey
Santa Monica
Other (please specify)
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5.
Are you or someone in your immediate family or household currently on jury duty or have you or someone in your immediate family or household received a notice calling you or them to serve on jury duty in the near future?
(Required.)
Yes
No
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6.
Are you a citizen of the United States?
(Required.)
Yes
No
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7.
Are you a registered voter in California or do you have a California Driver’s License?
(Required.)
Yes
No
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8.
Have you ever been convicted of a crime for which punishment could have been more than one year in confinement?
(Required.)
Yes
No
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9.
Are you now attending school, either full-time or part-time, during the day?
(Required.)
Yes
No
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10.
Are you responsible for providing primary, daily care to a child or other dependent?
(Required.)
Yes
No
