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(Fields marked with an asterisk "*" are required)
 

First Name:

*

Last Name:

*

Phone:

At least one is required between Cell, Home, and Work *

Cell:

Home:

Work:

Fax:

Home Address:

*

Home City:

*

Home State:

*

Home Zip:

*

Home County:

*

Type of Residence:

Email:

*

Date of Birth:

  *

Gender:

*

Ethnic Background:

*

Marital Status:

*

Education:

*

Employment Status:

*

Occupation Title (i.e. - Owner, President, Manager):

Occupation:

Industry:

Approximate Personal Income:

Approximate Household Income:

*

Do you suffer from any of the following?
(Specify which; Hold the <ctrl> key down to select/unselect multiple responses)

Please list any medications you take.
(Specify which; Hold the <ctrl> key down to select/unselect multiple responses)

Please list any health conditions suffered by someone you are a caregiver to.
(Specify which; Hold the <ctrl> key down to select/unselect multiple responses)

Do children in your household suffer from any of the following?
(Specify which; Hold the <ctrl> key down to select/unselect multiple responses)

Languages Spoken
(Specify which; Hold the <ctrl> key down to select/unselect multiple responses) 

 

 

 

 

Please List the name, date of birth and gender of children under the age of 18 living in your home. We invite children of all ages, and parents of children of all ages, to participate in our paid focus groups.

 

Child 1

First Name:

Birthdate:
 

Gender:

Child 2

First Name:

Birthdate:
 

Gender:

Child 3

First Name:

Birthdate:
 

Gender:

Child 4

First Name:

Birthdate:
 

Gender:

Child 5

First Name:

Birthdate:
 

Gender:

Child 6

First Name:

Birthdate:
 

Gender:


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:

  • Providing your personal information to Fieldwork constitutes your express written consent for collection, storing and processing your personal information.
  • Be truthful in answering questions about yourself and your habits.
  • Arrive for your appointment at least 15 minutes early and be ready to fully participate in the discussion.
  • Understand that anyone arriving late for their appointment may not be admitted into the study or be compensated.
  • Notify fieldwork if you must cancel with as much advance notice as possible. Both fieldwork and our clients are depending on your participation, and while we understand that circumstances may come up forcing you to cancel, with advance notice, we have the opportunity to try to recruit another interested participant.
  • Enjoy & contribute to the discussion! Focus Groups are fun and your opinions count!
Panelists under the age of 18 must have a Parent or Guardian's permission to participate.

*  I have read and understand my responsibilities as a participant and I agree to the terms and conditions above.