Join Our Database

Thank you for expressing an interest in being added to our database.   Market research is a tool used to continually improve products and services that are used by consumers. We do not sell anything, we collect opinions, and we compensate our participants. We do not sell our database to anyone; your information is kept completely confidential. Not even our clients can obtain any identifying data on our participants.
              
If this sounds like something you would like to do, please take the time to fill out the form below. Please be careful to answer all questions - leaving anything unanswered could leave out essential information in selecting participants for specific projects. You will be asked to enter your personal and then your household information. You may then register your spouse if you are married.  Any other adults age 18 or older must register themselves.

Once you submit this form you will be added to our database and we will call or email you soon. Your voluntary participation in Market research with Fieldwork constitutes an Independent Contractor relationship, not an Employment relationship.
      
(Fields marked with an asterisk “*” are required)
 

Promo Code

First Name:

*

Last Name:

*

Home Phone:

*

May we call you at work?

If yes, what is the number:         

Do you have a cell phone?

If you have a cell phone and we can call you on it please enter:           

What’s your fax # (if you have one)?

What’s your email address (if you have one)?

Home Address:

*

City:

*

State:

*

Zip:

*

County:

 

Country:

Date of Birth:

  *

Race:

(If Hispanic)What country were you born in?

(If Hispanic)What country were your ancestors born in?

What languages do you speak fluently? (Specify which; Hold the <ctrl> key down to select/unselect multiple responses)

Primary language spoken in home:

What language do you watch on television most of the time?

Gender:

Marital Status:

Highest grade of education completed:

What is your employment status?

What is your occupation?

Are you self-employed?    

Do you own a home-based business?

Party Affiliation:

Do you smoke?

Please think of the car you personally drive most often.  Do you primarily drive a:

What is the origin of your vehicle?

What class is your vehicle?

Have you been diagnosed by a medical professional with any of the following conditions? (Specify which; Hold the <ctrl> key down to select/unselect multiple responses)

Next, a few questions about your household:
 

Has anyone in your household been diagnosed by a medical professional
with any of the following conditions?
(Specify which; Hold the <ctrl> key down to select/unselect multiple responses)

Are you, or is anyone in your household  on any of the following diets? (Specify which; Hold the <ctrl> key down to select/unselect multiple responses) 

At home, which do you have:

Do you have a Computer for home use? Is it IBM or Mac compatible?
(Specify which; Hold the <ctrl> key down to select/unselect multiple responses)  

Are you Online at home? Is it high-speed access? If high
speed is it cable or modem?

Online?

Access speed?

Do you or does anyone in your household own a:
(Specify which; Hold the <ctrl> key down to select/unselect multiple responses)

Is your total household income:

What pets do you own? 
(Specify which; Hold the <ctrl> key down to select/unselect multiple responses)

Do you live in a:

Do you:

Type of community you live in:

Do you have children under 18 living at home? How many?

Please list the 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:

How did you hear about us?

 

 

 

 

THANK YOU!


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.