SurveyMonkey Powered Online Survey

Welcome and Thank you for taking the time to complete this application! Before you begin, please be aware that this is a bit more extensive than our normal survey's because it is a chance for you to enter a pool that will be automatically qualified for studies as they come up in the next few months. It is extremely important to be as honest as possible and take your time. Thank you again for participating!

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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:
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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.

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* 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. Gender:

Female

Male

Other (please specify)

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* 4. What is your age?

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* 5. How would you describe your ethnic or cultural background?

White or Caucasian

African American or Black

American Indian or Alaska Native

Asian/Pacific Islander

Hispanic/Latino

Mixed race

Other (please specify)