*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:
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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.Please fill in the following(Required.)

Name

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

*3.Which area of the country is your permanent residence?(Required.)

Northeast (Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, Connecticut, New York, New Jersey, and Pennsylvania)

Midwest OUTSIDE of Illinois (Ohio, Michigan, Indiana, Wisconsin, Minnesota, Iowa, Missouri, North Dakota, South Dakota, Nebraska, and Kansas)

Illinois

South (Delaware, Maryland, Virginia, West Virginia, Kentucky, North Carolina, South Carolina, Tennessee, Georgia, Florida, Alabama, Mississippi, Arkansas, Louisiana, Texas, and Oklahoma.)

West OUTSIDE of California (Montana, Idaho, Wyoming, Colorado, New Mexico, Arizona, Utah, Nevada, Oregon, Washington, Alaska, and Hawaii.)

California

*4.Which of the following best describes your current gender/gender identity?(Required.)

Male

Female

Non-binary

Other (please specify)

*5.To which age group do you belong?(Required.)

Under 18

18-27

28-43

44-59

60 or over

*6.What is your exact age?(Required.)

*7.With which ethnicity do you most identify?(Required.)

White, Caucasian, European, European-American

Hispanic, Latino, or Spanish

Black, African-American, Caribbean, African, Caribbean-American

Asian-American, Asian, Pacific Islander

American Indian, Native American

Other (please specify)

*8.What is the highest level of education you have completed?(Required.)

Some high school or less

Graduated high school

Some technical school or community college

Completed technical school or community college

Some undergraduate university or college

Completed undergraduate university or college

Some post graduate work

Completed post graduate work

*9.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