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)
 

First Name

*

Last Name

*

Home Address (note - PO boxes not acceptable)

*

City

*

Zip

*

Home Phone

 - - *

May we call you at work?

If yes, what is the number? 

 - -

May we call you on your cell phone?

If yes, what is the number?

 - -

Fax Number (if applicable)

 - -

Date of Birth

  *

Email Address
(note - We often notify database members of upcoming studies via email. If you do not have an email, please type NONE)

*

Gender

*

 

 

 

 

 

 

The next set of questions will help us know more about you.  The more we know - the higher the chance that your name will be chosen when a study comes up. Please fill in as much information as you are comfortable with.  Remember, all of your information is held strictly confidential.

 

 

 

 

 

 

Do you...?

Type of community you live in...

Marital Status

Race

Primary language spoken in home

Highest Grade of Education Completed

Are you employed...?

Occupation

Job Title

Do you own your own business?

Type of company you work for?

Type of industry you work in?

(If applicable) Spouse's Employment Status

(If applicable) Spouse's Occupation

Total Household Income

What speed is your internet connection at home?

Party Affiliation

Pet(s) [Hold <ctrl> key down to select/unselect multiple responses]

Do you smoke...?

What do you drive as your Primary Vehicle?

What is the origin of your Primary vehicle?

What class is your Primary vehicle?

 

 

 

 

 

 

What is the Make, Model, and Year of your 2 newest Vehicles:

 

 

 

 

 

 

Vehicle 1 make, model, year

Make

Model

Year

Vehicle 2 make, model, year

Make

Model

Year

Do you own a...? [Hold <ctrl> key down to select/unselect multiple responses]

At home, which of the following do you have? [Hold <ctrl> key down to select/unselect multiple responses]

Do you suffer from any of the following...?  [Hold <ctrl> key down to select/unselect multiple responses]

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

 

 

 

 

 

 

Please list the Name, Date of Birth, & Gender of each of your children.

 

 

 

 

 

 

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:
 

 

 

 

 

 

 

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Finally, if you are married and would like to register your spouse - please use the link on the next page to open up a new database form and enter his/her information.

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.