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.

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)
 

Basic Demographics

Promo Code:

First Name:

*

Last Name:

*

Home Phone:

*

Cell Phone:

Email:

Home Address:

*

City:

*

State:

*

Zip:

*

County:

Date of Birth:

*

Race:

Gender:

Marital Status:

Is your total household income:

Highest grade of education completed:

Type of community you live in:


Much of our research is conducted based on extended demographics that we collect on all respondents. Completing each additional section will greatly increase the chances of you being pulled up in our database for an upcoming project.

Household Information

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

Do you live in a:

Do you:

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:

Work Information

Work Phone:

Fax:

Job Function:

Job Title:

Are you self-employed?

Do you own a home-based business?

Company Name:

How many employees work at your location?

What is your employment status?

Industry:

Work Address:

Work City:

Work State:

*

Work Zip:

Interests and Hobbies

Party Affiliation:

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

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

Do you use streaming services?

Internet Provider:

Do you own a webcam?

Vehicle Manufacturer

Vehicle Year:

Primary Vehicle Type:

Do you own any of the following recreational vehicles
(Specify which; Hold the <ctrl> key down to select/unselect multiple responses)

What is the make of your primary cell phone?

What is your cellular service provider for your primary cell phone?

What mobile operating system do you use on your primary cell phone?

What of the following stores do you shop at?

Medical Health

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)

Have you been prescribed any medication by a medical professional (Specify which; Hold the <ctrl> key down to select/unselect multiple responses) 

Do you have health insurance? (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) 

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

 

 

 

 

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.
  • 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 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.