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26-430 Mock Jury
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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.
FOR IN PERSON RESEARCH:
In order to gain admittance to the facility, you need to bring:
A Photo ID
Reading glasses if you need them
Please make sure to self assess your health prior to the session and we ask that you cancel in advance if you are sick with Cold/Flu/Covid-19 symptoms.
Frequently we do not allow cell phones, smart watches, cameras or any electronic/digital devices into the research. There is a possiblity you will be asked to leave your devices with our front desk team where they will be kept securely during the research.
If qualified and based on these participation requirements, are you willing to participate in this in-person interview?
(Required.)
Yes
No
3.
By proceeding, you certify that all answers provided in this application are truthful, accurate, and complete to the best of your knowledge. You also confirm that you have completed this application independently, without the assistance of AI tools, chatbots, or other external aids. Lastly, you confirm that you live within the United States and are not suing a VPN to change your location in any way.
Please note:
The client reserves the right to disqualify and turn away any participant without compensation if any information provided is found to be untruthful, inaccurate, or generated by AI.
Do you agree with the conditions above?
Yes
No
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4.
CONTACT INFO
Please provide the following:
(Required.)
Name
City/Town
State/Province
ZIP/Postal Code
Email Address
Phone Number
5.
What gender do you identify as?
Male
Female
Non-Binary
Other (please specify)
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6.
What age range do you fall into?
(Required.)
18 and below
18 – 24
25 – 44
45 – 64
65 - 75
76+
7.
What is your exact age?
8.
What ethnicity do you identify as?
American Indian or Alaska Native
Asian or Asian American
Black or African American
Hispanic or Latino
Middle Eastern or North African
Native Hawaiian or other Pacific Islander
White
Another race
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9.
Are you a US Citizen with valid state ID?
(Required.)
Yes
No
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10.
Are you a resident of Orange County, CA?
(Required.)
Yes
No
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11.
Are you a full-time student?
(Required.)
Yes
No
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12.
Are you a convicted felon?
(Required.)
Yes
No
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13.
Are you or any member of your household currently under summons for jury duty?
(Required.)
Yes
No
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14.
Can you read and write in the English language with proficiency?
(Required.)
Yes
No
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15.
Have you participated in a focus group in the last 4 years?
(Required.)
Yes
No
