Skip to content
*
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.
CONTACT INFO
Please provide the following:
(Required.)
Name
*
Address
*
Apt # if applicable
City/Town
*
State/Province
*
ZIP/Postal Code
*
Email Address
*
Phone Number
*
*
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
*
4.
Which of the following best describes your current gender/gender identity?
(Required.)
Man
Woman
Non-binary or gender fluid
Other (please specify)
*
5.
What is your exact age?
(Required.)
*
6.
In which age range do you fall?
(Required.)
Under 18
18-19
20-24
25-30
31-34
35-40
41-44
45-50
51-54
55-64
65-75
Over 75
*
7.
When did you last participate in a market research study of any kind?
(Required.)
In the last 3 months
3-6 months ago
Over 6 months ago
Never
*
8.
On what topics have you participated in marketing research in the past year? If None put N/A
(Required.)
*
9.
What is your current marital status?
(Required.)
Single
Married or Co-habitating
Widowed, Divorced, or Separated
*
10.
Which of the following best describes your current employment status?
(Required.)
Employed full-time
Employed part-time
Full-time homemaker
Student
Not employed / Looking for work
Retired
*
11.
We are interested in speaking to people who work in various industries. What is your current occupation? If you are Retired please put you r prior occupation.
(Required.)
Job Title:
Employer:
Industry:
*
12.
Do you or does anyone in your household work in any of the following industries?
(Required.)
Education
Manufacturing
Marketing and Public Relations
Market research
Journalism or the media
Government
Financial services
. Telecommunications
None of the above
*
13.
Which, if any, of the following do you currently have and personally use?
(Required.)
Wireless phone/mobile service
Home Internet service
TV service from a Cable, Satellite, or Telecom provider
TV service from a streaming provider (i.e., SlingTV, YouTubeTV, etc.)
TV service using an antenna (Over-the-Air or OTA antenna)
Streaming video service (i.e., Netflix, Hulu, Amazon Prime Video, etc.)
Landline home phone service
I do not have any of these
