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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
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.
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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.
Where in the country do you live?
(Required.)
Southern CA
Northern CA
West outside of CA
Illinois
Midwest outside of Illinois
South
East
Northeast
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4.
In what state is your primary residence?
(Required.)
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5.
Do you identify as...
(Required.)
Male
Female
Transgender Male
Transgender Female
Non-Binary/Non-Conforming
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6.
What is your age please?
(Required.)
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7.
In which age range do you fall?
(Required.)
17 years or younger
18 – 25
26 – 34
35 – 44
45 – 54
55 years old or older
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8.
What is your relationship status?
(Required.)
Married
Divorced
In a relationship
Single
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9.
What is the age and gender of each person living in your household? If only you list your age and gender only.
(Required.)
Self -Age:
Self-Gender:
Other - Age:
Other - Gender:
Other - Age:
Other - Gender:
Other - Age:
Other - Gender:
Other - Age:
Other - Gender:
Other - Age:
Other - Gender:
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10.
When was the last time, if ever, you participated in a market research group discussion or one-on-one interview?
(Required.)
Less than 6 months ago
6 months-1 year ago
Over a year ago
Never
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11.
Are you currently scheduled to participate in any marketing research studies?
(Required.)
Yes
No
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12.
What is your current employment status?
(Required.)
A full-time employee
Working part-time
Laid-off / looking for work
A stay-at-home mom
Retired
Full-time student
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13.
Are you or is any member of your household employed by or retired from any of the following types of companies?
(Required.)
Advertising/public relations/marketing agency
Market Research company or market research department of a company
Newspaper, radio, magazine, or television station
Manufacturer, wholesaler, distributor, or retailer of food or beverages
A government agency associated with foods
None of the above
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14.
Do you, yourself, or does anyone in your household have any dietary restrictions due to…
(Required.)
Religious reasons
Those prescribed by a doctor or nutritionist
Medical conditions that require a special diet such as: Heart condition
Diabetes
Cancer or similar affliction
High blood pressure
Food allergies or sensitivities, e.g. wheat, dairy, soy, seafood, peanuts, eggs, tree, nuts, etc.
Aversion to specific foods, such as fried or pre-packaged foods
Nursing, pregnant, or expecting a pregnancy
None of the above
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15.
Or are on any special diets such as…
(Required.)
Vegetarian/Vegan
Paleo
Gluten Free
Lactose Free
Low sodium
Low sugar
None of the above
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16.
Please indicate to what degree you, yourself, participate in shopping for your household's food and beverages.
(Required.)
Almost always purchase food and beverages for the household
Share about equally the responsibility for purchasing food and beverages for the household
Sometimes purchase food and beverages for the household
Rarely or never purchase food and beverages for the household
