24-315 Survey

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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

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. CONTACT INFO Please provide the following:

Name *

Address *

Apt # if applicable

City/Town *

State/Province *

ZIP/Postal Code *

Email Address *

Phone Number *

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* 3. What is your gender

Male

Female

Non-Binary/Other

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* 4. What age range do yo fall under?

Under 18

18-20

21-23

23-27

28 or older

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* 5. What region do you live in?

Califonia

West outside of California

Illinois

Midwest outside of Illinois

North

South

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* 6. Which of the following best describes your racial or ethnic origin? Please note to indicate if you are of mixed descent as we are trying to encompass multiple ethnicities for this research project.

Black or African American

Asian or Asian American

White

Hispanic or Latino

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Middle Eastern or North African

Mix (Including Native American)

Mix (NOT including Native American)

Prefer not to answer