*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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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.Which of the following best describes your gender?

Male

Female

Non-Binary/Other

4.Which of the following best describes your ethnicity?

Caucasian

Hispanic

Black or African American

Asian

Other

5.Are you 18 years of age or older?

Yes

No

6.Which of the following age groups do you fall into?

Under 18

18-24

25-34

35-44

45-54

55-64

65+

7.What is your exact age?

8.What is your highest level of education?

Less than High School

High School Degree / GED

Some College / Associate’s-Degree

Bachelor’s Degree

Post-Graduate / Graduate Degree

9.What is your current employment status?

Full-Time

Part-Time

Unemployed

Disabled

Homemaker

Retired

10.What is your current job title and what is the name of your employer?

Job Title:

Employer: