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.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.

3.FOR IN PERSON RESEARCH:
In order to gain admittance to the facility, you need to bring:

A Photo ID
Reading glasses if you need them

Please make sure to self assess your health prior to the session and we ask that you cancel in advance if you are sick with Cold/Flu/Covid-19 symptoms.

Frequently we do not allow cell phones, smart watches, cameras or any electronic/digital devices into the research. There is a possiblity you will be asked to leave your devices with our front desk team where they will be kept securely during the research.

If qualified and based on these participation requirements, are you willing to participate in this in-person interview?(Required.)

Yes

No

4.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. Lastly, you confirm that you live within the United States and are not suing a VPN to change your location in any way.

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

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

Name

Address

Apt # if applicable

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

6.What gender do you identify as?

Male

Female

Non-Binary

Other (please specify)

8.What is your exact age?

11.Which is your dominant hand (i.e., which hand do you write with)?

Right

Left

Ambidextrous

13.Have you participated in a medical device study in the last 6 months?

Yes

No

14.Are you or is anyone in your household employed by any of the following?

Pharmaceutical or Medical Equipment Manufacturer

Marketing Research or Advertising Firm

Public Relations Firm

U.S. Food and Drug Administration (FDA) or consultant for the FDA

None of the above

15.Are you willing to use an autoinjector to inject into an injection pad without assistance?

Yes

No

16.Which of the following pertain to you?

Have an implanted medical device (e.g., pacemaker, defibrillator, cochlear implant, or any other mechanical/electro-mechanical device)

Allergic to Latex or Dry Natural Rubber

Pregnant, believe you may be pregnant, or are planning to become pregnant within the next 6 months

Wear a colostomy bag or related collection bag

None of the above

17.Do you have any professional medical training?
There are specific groups with and without training.

Yes

No