Grocery Shopping Study #4374

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* 1. Contact Information

First Name

Last Name

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 2. What is your age?

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* 3. What is your DOB?

Month/Day/Year

Date

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* 4. What is your gender?

Male

Female

Prefer to self-describe

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* 5. What is your ethnicity? (Select all that apply)

Asian

Black or African American

Pacific Islander or Native Hawaiian

Hispanic or Latino

Native American or Alaskan Native

White or Caucasian

Other (please specify)

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* 6. If you are selected to participate in this study, the session will be recorded for research purposes only. This information will not be shared publicly, and will solely be used for the purposes of this project.

Do you feel comfortable being recorded?

Yes

No