*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.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

3.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.

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

*4.CONTACT INFO Please provide the following:(Required.)

Name *

Address *

Apt # if applicable

City/Town *

State/Province *

ZIP/Postal Code *

Email Address *

Phone Number *

*5.Where in the country do you live?(Required.)

Southern CA

Northern CA

West outside of CA

Illinois

Midwest outside of Illinois

South

East

Northeast

6.These groups are taking place in the Chicago Area In-Person. Are you willing and able to attend an in person focus group on either June 8th or June 9th?

Yes

No