Focus group qualification survey Question Title 1. Thank you for taking a moment to fill out this quick survey. We will use this information to select qualified applicants for upcoming paid focus group discussions around the state of Alaska. Please fill out this survey honestly. If you do not meet the criteria for a particular group right now, we will keep your information on file for other opportunities that come up in the future. We do not sell this information or release it to any third party for any reason. We only use this information for selecting research participants. What is your first name? Question Title 2. What is your last name? Question Title 3. What is your gender? Female Male Question Title 4. What is the highest level of education you have completed? Less than high school High school graduate Some college Associates degree College graduate (Bachelors degree) Graduate / Professional degree Question Title 5. In what year were you born? (enter 4-digit birth year; for example, 1976) Question Title 6. Do you have any children under 18 years old living in your household? Yes No Question Title 7. What is your occupation? (if not currently employed, a student, or retired, please indicate so in the answer box.) Question Title 8. What is the name of your employer (former employer if retired)? Question Title 9. What is your approximate annual household income? (Why do we ask this question? It helps us select people with a variety of income ranges for different focus groups and research projects) $0-$34,999 $35,000-$49,999 $50,000-$74,999 $75,000-$99,999 $100,000-$124,999 $125,000-$149,999 $150,000 or more $150,000-$174,999 $175,000-$199,999 $200,000 and up Question Title 10. In the past 30 days, have you used any of the following tobacco products: Cigarettes, Cigars, Dipping or Chewing Tobacco, or Electronic Cigarettes? Yes No Question Title 11. What is your phone number? (note: we will not sell your number, or contact you for anything except about upcoming focus group opportunities that you might qualify to participate in) Question Title 12. What is your email address? (again, we will not sell your email address, or use it for anything except contacting you about focus groups that you might qualify for) Question Title 13. In what ZIP code is your home located? (enter 5-digit ZIP code; for example, 00544 or 94305) Question Title 14. What community do you currently live in or near (as in you would be able to travel to this community to participate in a focus group)? Anchorage Bethel Dillingham Eagle River Fairbanks Homer Juneau Kenai/Soldotna Ketchikan Kodiak Kotzebue Nome Palmer Seward Sitka Utqiagvik Valdez Wasilla Yakutat Barrow Other (please specify) Question Title 15. What is your race? African American American Indian / Alaska Native Asian Hispanic Native Hawaiian / Pacific Islander White Other Question Title 16. In general, how would you describe your views on most political issues? (Why do we ask this question? Often we conduct political focus groups and knowing your general political views helps us select people from a variety of backgrounds. Answering this question is optional.) Very conservative Somewhat conservative Independent - lean conservative Independent - no lean Independent - lean liberal Somewhat liberal Very liberal Done
