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 PLEASE ENTER YOUR PERSONAL INFO  (Fields marked with '*' are required)

FIRST NAME *
LAST NAME *
SSN (last 4 numbers)
DRIVER LICENSE
HOME PHONE * () -
WORK PHONE () - Ext.
MOBILE PHONE () -
FAX () -
DATE OF BIRTH *
E-MAIL *
ADDRESS *
CITY *
STATE *
ZIP *
  

 PLEASE FILL OUT THIS QUESTIONAIRE
The following information will be used to assist us in conducting focus group discussions on a variety of topics from technology, food, music, cosmetics, to discussing more current events. The Focus Room recruits individuals from diverse social, religious, educational and sexual backgrounds. All information provided is strictly confidential.
 1. GENDER
  MALE   FEMALE


 2. PREFIX:
  MISS   MRS   MR
  DR


 3. WHICH OF THE FOLLOWING CATEGORIES INCLUDES YOUR AGE?


 4. ETHNIC CATEGORY
  AFRICAN AMERICAN   ASIAN   CAUCASIAN
  HISPANIC   NATIVE AMERICAN   MULTI-RACIAL
  OTHER      


 5. MARITAL STATUS


 6. WHAT IS YOUR SEXUAL ORIENTATION
   HETEROSEXUAL    HOMOSEXUAL    REFUSE TO ANSWER


 7. CHILDREN
     
     
     
     
     


 8. EDUCATION:
  HIGH SCHOOL   COLLEGE STUDENT   SOME COLLEGE
  COLLEGE GRADUATE   GRADUATE SCHOOL   TRADE SCHOOL (SPECIFY)      


 9. WHAT IS YOUR CURRENT EMPLOYMENT STATUS?
  WORK FULL TIME   WORK PART TIME   NOT WORKING
  RETIRED   HOUSEWIFE


 10. WHICH JOB CATEGORY BEST DESCRIBES YOUR OCCUPATION ?
     


 11. TOTAL INCOME


 12. DO YOU OWN OR RENT YOUR OWN HOME?
  OWN   RENT   OTHER (SPECIFY)      


 13. PETS
   CAT    DOG    OTHER (SPECIFY)      
   NO PETS


 14. DO YOU OWN OR LEASE A VEHICLE?
  OWN   LEASE   BOTH OWN AND LEASE
  NEITHER


 15. HOW MANY VEHICLES (IN TOTAL) DO YOU OWN OR LEASE?
   ONE    TWO    THREE
   FOUR    DO NOT HAVE A VEHICLE


 16. CAR MAKE/ MODEL