*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 (First and last)

Address

City

State

Zip code

Phone

email

*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.With which gender do you identify?(Required.)

Male

Female

Non-binary

Other (please specify)

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

Under 18

18-24

25-38

39-51

52-64

Over 64

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

7.With which ethnicity do you identify? Please check all that apply

White

Black or African American

Hispanic or Latino

Asian or Asian American

Other (please specify)

*8.Have you ever participated in a focus group, a panel discussion, or an individual interview conducted by a marketing research company?(Required.)

Yes

No