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First Name:

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Last Name:

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Home Phone:

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What’s your email address?

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May we call you at work?

If yes, what is the number?

If you have a cell phone and we can call you on it, please give us that number:

Date of Birth: 

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Gender:

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Marital Status:

Ethnic Background:

Highest level of education completed:

Are you employed:

Is your total household income:

Party Affiliation:

Do you own a cat, dog or other pet?

Do you smoke?

Do you have a Computer for home use?

Are you Online at home?  What is your access?

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

What is your residence?

Home Address

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City

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State

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Zip

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County

Please list the Date of Birth and Gender of each child in your household under the age of 18:

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:

  • 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.