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(Fields marked with an asterisk "*" are required)
First Name:
*
Last Name:
Home Phone:
1---*
May we call you at work?
(If yes) Work Phone:
1---
Do you have a cell phone?
(If we can call you on it) Cell Phone:
Email Address:
Home Address:
City:
Abba Abbeville Acworth Adairsville Adel Adrian Ailey Alamo Alapaha Albany Aldora Allenhurst Allentown Alma Alma Alpharetta Alston Alto Amboy Ambrose Americus Andersonville Appling Arabi Arcade Arlington Ashburn Athens Atkinson Atlanta Attapulgus Auburn Augusta Austell Avera Avondale Estates Axson Baconton Baden Bainbridge Baldwin Bannockburn Barnesville Barney Barretts Barwick Baxley Bemiss Berkeley Lake Berlin Bethlehem Bishop Blackshear Blairsville Blakely Bloomingdale Blue Ridge Bluffton Blythe Bogart Boston Bostwick Bowdon Bowens Mill Bowman Braselton Bremen Brinson Bristol Bronwood Brookfield Brooklet Brooks Broxton Brunswick Buchanan Buckhead Buena Vista Buford Bushnell Butler Byromville Byron Cairo Calhoun Camak Camilla Canon Canton Carl Carlton Carnesville Carrollton Cartersville Cave Spring Cecil Cedartown Centerville Chamblee Chatsworth Chauncey Chester Chickamauga Chula Clarkesville Clarkston Claxton Clayton Clermont Cleveland Clyatteville Clyo Cobbtown Cochran Cogdell Cohutta Colesburg College Park Collins Colquitt Columbus Commerce Concord Conyers Coolidge Cordele Cornelia Council Coverdale Covington Cox Crawfordville Crescent Culloden Cumming Cusseta Cuthbert Dacula Dahlonega Daisy Dakota Dallas Dalton Damascus Danielsville Darien Dasher Dawson Dawsonville Decatur Denmark Dillard Dixie Dock Junction Doerun Donalsonville Doraville Douglas Douglasville Dover Bluff Dublin Dudley Duluth Dunwoody DuPont East Dublin East Point Eastman Eatonton Ebenezer Edison Edith Egypt Elberton Eldorado Ellabelle Ellaville Ellenton Ellenwood Ellijay Enigma Euharlee Eulonia Everitt Fairburn Fairmount Fargo Fayetteville Fitzgerald Flemington Flowery Branch Folkston Forest Park Forsyth Fort Gaines Fort Oglethorpe Fort Stewart Fort Valley Franklin Fruitland Funston Gainesville Garden City Garfield Geneva Georgetown Gibson Glennville Glenwood Glory Graham Gray Grayson Greensboro Greenville Griffin Grooverville Groveland Grovetown Gumbranch Guyton Hagan Hahira Hamilton Hampton Hapeville Harding Harding Hardwicke Harlem Harrietts Bluff Hartwell Hawkinsville Haylon Hazlehurst Helen Helena Hepzibah Hiawassee Hickox Higgston Hinesville Hiram Hoboken Hogansville Holly Springs Holt Homeland Homer Homerville Hopeulikit Hortense Hoschton Howell Inaha Iron City Irwinton Irwinville Jackson Janis Jasper Jefferson Jeffersonville Jesup Johns Creek Jonesboro Keller Kennesaw Kinderlou Kings Bay Base Kingsland Kirkland Kite LaFayette LaGrange Lake City Lake Park Lakeland Lanier Lavonia Lawrenceville Lax Leary Leefield Leesburg Lenox Lexington Lilburn Lincolnton Lithia Springs Lithonia Locust Grove Loganville Lookout Mountain Louisville Lovejoy Ludowici Lula Lulaton Lumber City Lumpkin Luthersville Lyerly Lyons Mableton Macon Madison Manassas Manchester Mansfield Marietta Maxeys Mayday Maysville McCaysville McDonough McIntosh McIntyre McRae Meansville Meigs Meldrim Menlo Mershon Metter Midway Milan Milledgeville Millen Milton Moniac Monroe Montezuma Montgomery Monticello Montrose Mora Morgan Morganton Morrow Morven Moultrie Mount Airy Mount Vernon Mount Zion Mountain Park Mystic Nahunta Nankin Nashville Needmore Nelson Nevils New Rock Hill Newnan Newton Nicholls Nicholson Norcross Norman Park Oakwood Ochlocknee Ocilla Odum Offerman Oglethorpe Oliver Omega Osterfield Ousley Oxford Palmetto Parrott Patterson Peachtree City Pearson Pelham Pembroke Pendergrass Perry Phillipsburg Pine Lake Pine Mountain Pinehurst Pineora Pineview Plains Pooler Port Wentworth Portal Potter Poulan Powder Springs Preston Pridgen Pulaski Queensland Quitman Race Pond Ranger Ray City Rebecca Register Reidsville Remerton Rentz Resaca Retreat Rex Riceboro Richmond Hill Ridgeville Rincon Ringgold Riverdale Riverside Roberta Rochelle Rockingham Rockmart Rome Roswell Royston Rutledge Saint George Sale City Sandersville Sandy Springs Sasser Savannah Screven Senoia Sessoms Shawnee Shellman Bluff Sirmans Skidaway Island Smithville Smyrna Snellville Social Circle Soperton South Newport Sparks Sparta Springfield St. Marys St. Simons Island Statenville Statesboro Sterling Stillmore Stillwell Stilson Stockbridge Stockton Stone Mountain Sugar Hill Summerville Sumner Sunbury Sunsweet Surrency Suwanee Swainsboro Sycamore Sylvania Sylvester Talbotton Tallapoosa Tarboro Tarver Temple Thalman Thelma Thomaston Thomasville Thomson Thunderbolt Tifton Toccoa Toomsboro Townsend Trenton Trudie Tucker Twin City Twin Lakes Ty Ty Tybee Island Tyrone Unadilla Union City Union Point Unionville Upton Uvalda Valdosta Valona Vernonburg Vidalia Vienna Villa Rica Walthourville Warner Robins Warrenton Warwick Washington Waterloo Watkinsville Waverly Waycross Waynesboro Waynesville Weber West Green West Point Westwood Whigham White Oak Whitmarsh Island Willacoochee Wilmington Island Winder Winokur Winston Withers Woodbine Woodstock Worth Wray Wrightsville Young Harris Zebulon *
State:
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming *
Zip:
County:
Date of Birth:
Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 *
Race:
African American Asian Caucasian Egyptian Hispanic Middle Eastern Multi-Racial Native American Oriental
Gender:
Male Female
Marital Status:
Divorced/Separated Married Single Widowed
Employment Status:
Full Time Part Time Homemaker Retired Student Unemployed
Occupation:
Accountant Accounts Payable Adjustor Administrative Administrator Advertising Advisor Agent Analyst Architect Artist Assistant Associate Attorney Auditor Banker Bartender Beautician Bookkeeper Broker Builder Buyer Caregiver Caretaker Carpenter Cashier Caterer Chef Chief Executive Officer Chief Financial Officer Childcare Chiropractor Clerk Coach Collector Consultant Contractor Controller Coordinator Counselor Custodian Daycare Dealer Dentist Designer Detective Developer Dietician Director Distributor Editor Educator Electrician Engineer Examiner Executive Fireman Florist Homemaker Housekeeper Hygenist Inspector Instructor Investigator Laborer Landscaper Maintenance Manager Marketing Mechanic Merchandizer Military Minister Model Musician Nurse Nutritionist Officer Operator Owner Painter Paralegal Paramedic Pathologist Pharmacist Photographer Physician Pilot Planner Plumber President Principal Printer Producer Professor Programmer Psychiatrist Psychologist Public Relations Radiologist Realtor Receptionist Remodeling Representative Retired Sales Scientist Secretary Self Employed Social Worker Software Specialist Student Superintendent Supervisor Surgeon Teacher Technician Teller Therapist Trainer Transcriptionist Transportation Treasurer Underwriter Veterinarian Vice President Waiter/waitress Writer Unknown
Job Title:
Do you own a cat, dog or other pet?
Dog Cat Both None Other
Do you smoke?
Yes No
Number of children under 18 living at home:
None 1 2 3 4 5 6 or more
Please list Date of Birth & Gender of each child
Child 1:
Birthdate: Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 201320142015201620172018
Gender: Male Female
Child 2:
Child 3:
Child 4:
Child 5:
Child 6:
Promo Code:
Much of our research is conducted based on extended demographics that we collect on all respondents. Completing an additional section will greatly increase the chances of you being pulled up in our database for an upcoming project.
Would you like to enter extended demographics?
Highest grade of education completed:
Grade School High School Trade School Some College College Graduate Post Graduate
Party Affiliation:
Democrat Republican Independent
Spouse’s Employment Status:
Spouse’s Occupation:
Accountant Accounts Payable Adjustor Administrative Administrator Advertising Advisor Agent Analyst Architect Artist Assistant Associate Attorney Auditor Banker Bartender Beautician Bookkeeper Broker Builder Buyer Caregiver Caretaker Carpenter Cashier Caterer Chef Chief Executive Officer Chief Financial Officer Childcare Chiropractor Clerk Coach Collector Consultant Contractor Controller Coordinator Counselor Custodian Daycare Dealer Dentist Designer Detective Developer Dietician Director Distributor Editor Educator Electrician Engineer Examiner Executive Fireman Florist Homemaker Housekeeper Hygenist Inspector Instructor Investigator Laborer Landscaper Maintenance Manager Marketing Mechanic Merchandizer Military Minister Model Musician Nurse Nutritionist Officer Operator Owner Painter Paralegal Paramedic Pathologist Pharmacist Photographer Physician Pilot Planner Plumber President Principal Printer Producer Professor Programmer Psychiatrist Psychologist Public Relations Radiologist Realtor Receptionist Remodeling Representative Retired Sales Scientist Secretary Self Employed Social Worker Software Specialist Student Superintendant Supervisor Surgeon Teacher Technician Teller Therapist Trainer Transcriptionist Transportation Treasurer Underwriter Veterinarian Vice President Waiter/waitress Writer Unknown
Do you suffer from any of the following? (Specify which; Hold the <ctrl> key down to select/unselect multiple responses)
Allergies Asthma Blood Pressure/Hypertension Cancer Cholesterol Diabetes Overweight
Does anyone else in household suffer from: (Specify which; Hold the <ctrl> key down to select/unselect multiple responses)
Allergies Asthma Hypertension/Blood Pressure Cancer Cholesterol Diabetes Overweight
Primary Vehicle:
Car Coupe Mini Van Truck Sedan SUV Van None
TV service at home:
Cable Satellite None Both
Type of internet access:
Not online at home T1 Line Dial up DSL Cable
Do you have a Computer at home?
Do you own a home-based business?
What’s your fax #?
Housing Situation:
Condo Owner Home Owner Renter Live with parents
Household Income:
Under $20,000 $20,000 - $35,000 $36,000 - $50,000 $51,000 - $75,000 $76,000 - $100,000 $101,000 - $150,000 $151,000 - $200-000 More than $200,000
What are my responsibilities as a focus group participant?
Fieldwork and its clients rely on the integrity of focus group respondents to conduct accurate and meaningful research. We ask that you commit to the following:
