* 1. First and Last Name:

* 2. Phone number:

* 3. Email address:

* 4. What is your zip code?

* 5. Are you the female head of household?

* 6. What is your exact age?

* 7. Please tell me to what degree you, yourself, participate in shopping for the groceries that you buy for your household. Would you say you...?

* 8. Please indicate if you or anyone in your family work for any of the following types of companies or occupations.

* 9. Has any member of your immediate family been employed at any of the following companies in the past 3 years? (Immediate family includes the following: parents/step parents, grandparents, siblings, children/step children, spouse/significant other, and anyone living in the same house)

* 10. In the past 6 months, have you participated in a group discussion or interview regarding a product or service?

* 11. Have you ever participated in a group discussion or individual interview concerning any of the following products:

* 12. Which ethnic background do you consider yourself to be?

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