*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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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.

*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 area of the country is your permanent residence?(Required.)

Northeast (Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, Connecticut, New York, New Jersey, and Pennsylvania)

Midwest OUTSIDE of Illinois (Ohio, Michigan, Indiana, Wisconsin, Minnesota, Iowa, Missouri, North Dakota, South Dakota, Nebraska, and Kansas)

Illinois

South (Delaware, Maryland, Virginia, West Virginia, Kentucky, North Carolina, South Carolina, Tennessee, Georgia, Florida, Alabama, Mississippi, Arkansas, Louisiana, Texas, and Oklahoma.)

West OUTSIDE of California (Montana, Idaho, Wyoming, Colorado, New Mexico, Arizona, Utah, Nevada, Oregon, Washington, Alaska, and Hawaii.)

California

4.Which of the following best describes your current gender/gender identity?

Male

Female

Nonbinary

Other (please specify)

5.What age range do you fall into?

Under 18

18-24

25-34

35-44

45-54

55+

6.What is your exact age?

7.What is your self-identified race or ethnicity?

Black, African-American, Caribbean, African, Caribbean-American

Hispanic / Latino / Latina or Spanish origin

Asian-American, Asian, Pacific Islander

White, Caucasian, European, European-American

Other (please specify)

8.What is the highest level of education you have completed?

Some high school or less

High school graduate

Currently in college

Some college

College graduate

Some graduate school

Graduate school

9.Which of the following best describes your household’s total monthly income, after taxes?

Less than $25,000

$25,000 to less than $50,000

$50,000 to less than $75,000

$50,000 to less than $100,000

$100,000 to less than $125,000

$125,000 to less than $150,000

$150,000 to less than $250,000

$250,000 to less than $500,000

$500,000 to less than $1,000,000

$1,000,000 or more

10.Which of the following best describes your current employment status?

Employed full-time

Employed part-time

Self-Employed or freelance

Stay-At-Home Parent or Homemaker

Student

Retired

Not employed / Looking for work