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

First Name:

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Last Name:

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Home Phone:

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May we call you at work?

If yes, what is the number:

If you have a cell phone & we can call you on it please write it here:

Date of Birth: 

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Race:

Gender:

Marital Status:

Highest grade of education completed:

Are you employed:

Occupation?

Job Title?

Party Affiliation:

Is your total household income:

Spouse’s Employment Status:

Spouse’s Occupation:

Children under 18 living at home? How many?

Do you own cat, dog, or other pet?

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

Does anyone else in household suffer from: (Specify which; Hold the <ctrl> key down to select/unselect multiple responses)

Do you smoke?

Please list the
year, make and model of the 2 primary
vehicles owned by your household.

Make

Model

Year

Make

Model

Year

At home, which do you have:

Do you have a Computer for home use? Is it IBM or Mac compatible?  Which?

 

 

Are you Online at home?  Is it high-speed access?

Do you own a: (Specify which; Hold the <ctrl> key down to select/unselect multiple responses)

Do you own a home-based business?

Type of company you work for?

For what type of industry do you work?

What’s your fax #?

What’s your email address?

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Home Address (including city & zip):

Address

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City

*

State

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Zip

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County

Do you own a single family home or a condo or rent? Do you live with your parents?

Please list the First Name, Date of Birth & Gender of each child:

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:

 

 

 

 

 

 

Promo Code

 

 

 

 

 

 


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:

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  • 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.

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