* Indicates Required Information
first name*
last name*
address
city
state
zip
home phone
cell phone
work phone
fax
email*
1. Which of the following best describes your employment status?
2. What is your occupation?
3. What is your title?
4. What industry do you work?
5. Into which of the following categories does your age fall?
6. What is your marital status?
7. Which is the last level of education you completed? Please choose only one.
8. Into which of the following categories does your annual household income fall? This includes all members of your household.
9. Which of the following best describes your ethnic background?
10. What are the ages and sex of your children?
Child 1: M F Child 2: M F Child 3: M F Child 4: M F No children
11. Which of the following best describes your living situation?
12. What time(s) of day would you be available to attend a focus group? Focus groups usually last 1 1/2 to 2 hours.
