Thank you for expressing interest in joining our database!

Please be careful to answer all questions - leaving anything unanswered could leave out essential information in selecting participants for specific projects. Your information is securely transferred to our systems and personally identifiable information is never shared with anyone else. Your voluntary participation in Market research with Fieldwork constitutes an Independent Contractor relationship, not an Employment relationship.

If at any time you wish to unsubscribe from our database, you may call the office you signed up with or fill out this unsubscribe form.

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

We have offices in Fort Lee, NJ and NYC. Select which office(s)

where you would like to participate:

*

First Name:

*

Last Name:

*

Phone:

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

Cell: 1-

--

Home: 1-

--

Work: 1-

--

Fax: 1-

--

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:

The more information you provide, the more likely you are to qualify for groups.

Occupation:

Industry:

Employer Name:

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.
  • You have read and agree to the terms in our Privacy Policy.
  • Be truthful in answering questions about yourself and your habits. You certify all information provided is accurate as of the date of your offering the information either electronically, on paper, or verbally.
  • 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 s 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 register and participate.
*  I have read and understand my responsibilities as a participant and I agree to the terms and conditions above.