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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
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3.
Please fill in the following
(Required.)
Name
Address
City/Town
State/Province
ZIP/Postal Code
Email Address
Phone Number
4.
In which county is your permanent address?
Los Angeles
Orange County
San Bernardino
Ventura
Riverside
Other (please specify)
5.
Do you identify as…
Male
Female
Non-binary
Other (please specify)
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6.
To which age group do you belong?
(Required.)
Under 18
18-28
29-44
45-60
61+
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7.
What is your exact age?
(Required.)
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8.
With which ethnicity do you most identify?
(Required.)
White
Black or African American
Hispanic or Latino
Asian or Asian American
Other (please specify)
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9.
What is your relationship status?
(Required.)
Married
In a relationship
Single
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10.
Whatis your household makeup? Please check all that apply
(Required.)
I live with Kids ages 5-18
I live alone
I live with a partner/spouse
I live with my parents/family
I live with roommates
11.
What is the age, gender, and relationship to you of each person who live in the same household as you?
Age
Gender
Relationship
Age
Gender
Relationship
Age
Gender
Relationship
Age
Gender
Relationship
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12.
What is current employment status? Are you…
(Required.)
Full-time employee
Working part-time
Laid-off / looking for work
A stay-at-home parent/homemaker
Part time student
Full-time student
Retired
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13.
When was the last time, if ever, you participated in a market research group discussion or one-on-one interview? Would you say
(Required.)
Less than 6 months ago
6 months-1 year ago
Over a year ago
Never
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14.
What were the topics?
(Required.)
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15.
Are you currently scheduled to participate in any marketing research studies at [COMPANY] or any other company, or not?
(Required.)
Yes
No
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16.
Are you or is any member of your household employed by or retired from any of the following types of companies? Check all that apply
(Required.)
An advertising agency or advertising department of a company?
A market research firm or the market research department of a company?
A public relations firm?
A TV or radio station?
A convenience store, either in-store or in a distribution center or related office?
A supermarket, either in-store or in a distribution center or a related office?
A mass merchandiser (such as a Walmart, Target or Kmart) either in-store or in a distribution center or a related office?
A drugstore, either in-store or in a distribution center or a related office?
A manufacturer, distributor or wholesaler of food products, including Chef?
A consulting firm that works with manufacturers of food products?
A package design firm working with manufacturers of food products?
None of the above
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17.
Do you, yourself, have any dietary restrictions due to...? Check all that apply
(Required.)
Yes
No
1. Religious reasons
Yes
No
2. Those prescribed by a doctor or nutritionist
Yes
No
3. Medical conditions that require a special diet such as:
a. Heart condition
Yes
No
b. Diabetes
Yes
No
c. Cancer or similar affliction
Yes
No
d. Other
Yes
No
4. Food allergies -
Yes
No
5. Aversion to specific foods, such as pre-packaged foods
Yes
No
6. Or are on any special diets such as…...?
a. Vegetarian/Vegan
Yes
No
b. Low Sodium
Yes
No
c. Low Sugar
Yes
No
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18.
Are you pregnant or nursing?
(Required.)
Yes
No
I am male
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19.
Please tell me to what degree you, yourself, participate in choosing/purchasing the groceries in your household. Would you say you
(Required.)
Almost always make grocery purchase decisions for the household
Share about equally the responsibility of grocery purchase decisions for the household
Sometimes make grocery purchase decisions for the household
Rarely or never make grocery purchase decisions for the household
