Be paid for your opinions!

We are pleased to include you in our database of research panelists. We conduct discussion groups and interviews for clients who want information on various topics, (e.g. customer and product satisfaction, quality control, advertising and product development ideas). Our clients are looking for people who fit a profile or group of profiles and they appreciate the value of your time, so they pay "incentives" usually from $50 to $200 or more, depending on the topic and duration.

The questionnaire takes about 5-10 minutes; it is divided into basic demographic information and information about your lifestyle and preferences.

We often post information about studies on our Facebook Page. Be sure to like us on Facebook to keep up to date on upcoming studies.

None of the information included here will be used for sales purposes or given to other companies.

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1. What type of research are you interested in participating in?

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2. In what location(s) would you be willing to participate in a focus group or interview? (please check all that apply)

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3. Name (Required.)

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4. Gender

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5. Ethnicity

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6. Do you speak a language in addition to English?

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7. Birthdate

Date

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8. Email address-Please provide us with the email address to which you would correspondence about research studies. Your email will be used for that purpose only and will not be shared.

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9. Address

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10. Telephone Number (Required.)

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11. Marital Status

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12. Do you own or rent your primary residence?

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13. Please provide us with information about your voter registration

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14. Please provide us with information about your children, please include both children that live in your household and grown children who live outside of your household.

  Gender of child
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6

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15. Birthdates of your child(ren)

Date
Date
Date
Date
Date
Date

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16. Current employment status

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17. Current job title

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18. Current employer

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19. Company size of current employer (all locations)

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20. Occupation (If you are not employed or are retired, but have previously worked, please indicate your former occupation.

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21. What is your highest level of education?

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22. Which of these categories best describes the combined annual income of all members of your household (before taxes)?

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23. Do you or anyone in your household have any of the following health conditions (please check as many or as few apply to you)

  Who has this condition?
ADD/ADHD
Allergies
Alzheimers
Asthma
Back Pain
Cancer
Physical Disability
Emotional Disability
COPD
Crohn's Disease
Depression
Diabetes - Type 1
Diabetes - Type 2
Epilepsy
Gastrointestinal Issues/GERD
Hearing Impairment
Heart Condition
High Blood Pressure/Hypertension
High Cholesterol
Incontinence/Stress Incontinence
IBS/Chronic Diarrhea or Constipation
Menopause
Mental Health Disorders other than Depression
Multiple Sclerosis
Osteoporosis
Chronic Pain Condition
Pregnancy/Childbirth
Psoriasis/Psoriatic Arthritis
Rheumatoid Arthritis
Sleep Disorder
Stroke
Thyroid Condition
Visual Impairment (Blindness)
Visual Impairment (Retinopathy,other)
Weight Control Concerns

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24. Do you have health insurance? (please check as many or as few apply to you)

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25. On average, how many prescriptions are you responsible for filling each month for your household? (include refills)

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26. Where do you fill or refill prescriptions? (Please check all that apply)

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27. Which type of cellular phone do you use?

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28. Were you referred to us by someone you know? (If so, please specify first/last name as we offer referral incentives often)

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29. If you were not referred by someone you know,how did you hear about us? (please check as many or as few as apply to you)

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30. Please let us know about any sports, hobbies or interests that you pursue. Is there anything else you would like us to know about you?

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31. Please provide us with names and email of people who may be interested in participating in research.

Thank you for your time and interest. We look forward to contacting you with a suitable project.
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