Question Title * 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 InfoFinancial Incentive InfoAdler Weiner Privacy Policy 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. Question Title * 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? Yes No Question Title * 3. Please fill in the following Name (First and Last) City Zip Code Phone Email Question Title * 4. In which county is your permanent address? Los Angeles Orange County San Bernardino Ventura Riverside Other (please specify) Question Title * 5. With which gender do you identify? Male Female Non-binary Other (please specify) Question Title * 6. To which age group do you belong? Under 21 21 - 29 30 - 39 40 - 49 50 – 59 60 – 69 70 or over Question Title * 7. What is your exact age? Question Title * 8. With which ethnicity do you identify? Check all that apply White Black or African American Hispanic or Latino Asian or Asian American Other (please specify) Question Title * 9. Do you currently, or does anyone in your immediately family, work in any of the following businesses? Yes No Education Education Yes Education No Market Research Market Research Yes Market Research No Banking or Credit Card Company Banking or Credit Card Company Yes Banking or Credit Card Company No Media (e.g. TV, website, radio, magazine, newspaper, blogs, freelance writing) Media (e.g. TV, website, radio, magazine, newspaper, blogs, freelance writing) Yes Media (e.g. TV, website, radio, magazine, newspaper, blogs, freelance writing) No Advertising or Public Relations Advertising or Public Relations Yes Advertising or Public Relations No Healthcare Healthcare Yes Healthcare No Question Title * 10. Have you ever participated in a market research group or one-on-one discussion? Yes No Next
