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.
Please fill in the following
(Required.)
Name
Address
City/Town
ZIP/Postal Code
Email Address
Phone Number
*
3.
In which county is your permanent residence?
(Required.)
Los Angeles
Orange County
Ventura
San Bernardino
Riverside
Other (please specify)
*
4.
Which of the following best describes your gender?
(Required.)
Male
Female
Non-binary
Other (please specify)
*
5.
To which age group do you belong?
(Required.)
Under 18
18 – 27
28 – 34
35 – 44
45 – 54
55 – 65
66 or over
*
6.
What is your exact age?
(Required.)
*
7.
With which ethnicity do you most identify?
(Required.)
Black or African American
American Indian or Alaska Native
Asian or Asian American
Native Hawaiian or other Pacific Islander
Hispanic or Latino
White
Other (please specify)
*
8.
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
*
9.
What is/was yourJob Title, Company Name and Industry
(Required.)
Job Title
Company Name
Industry
*
10.
Do you or does anyone in your household work in any of the following industries?
(Required.)
Yes
No
Advertising agency or public relations firm
Yes
No
Marketing research company
Yes
No
Industry analyst firm
Yes
No
Electronics, computer hardware or software industries
Yes
No
Home security industry
Yes
No
eCommerce / Online retailer
Yes
No
Broadcast industry or television station
Yes
No
IT or tech industry
Yes
No
Energy-supply, including power and gas companies
Yes
No
Education, including teachers and administration
Yes
No
*
11.
When was the last time you participated in a market research study of any kind – such as a one-on-one interview, group discussion, opinion survey, or a product test in which you were asked to rate or discuss products, ideas, or advertising?
(Required.)
Within the last 3 months
3-6 months ago
6-12 months ago
1-2 years ago
3 or more years ago
