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Welcome to the United States Focus Group Register
The purpose of this is to develop a data base of potentially available focus group respondents from all over the country. We are looking for respondents from large cities and small towns. They might participate in focus group meetings or extended telephone conferences.
When you fill out this, or any other questionnaire, be totally honest. The facilities who recruit have no control over the types of people they are going to recruit. They are given specifications -- Women.35-40 who have two dogs and an income under $50,000 a year; or men who live in homes with wood siding and consider themselves home handymen...or not .
You just never know.
Your questionnaire will be shared with a major focus group organization for recruiting purposes only. Let's begin.....


The first questions will tell us how we get in touch with you and where you live.


1.
First Name?

2.
Last Name?

3.
E-mail address

4.
Telephone number

5.
Cell phone number

6.
City

7.
State

8.
ZIP

  Now just a little bit about who you are.  

9.
Gender
Female
Male

10.
Month and Year of your birth
MONTH: Jan: 1/Feb: 2/Mar: 3 /Apr: 4/May: 5/ June: 6
Jul: 7/ Aug: 8/ Sep: 9/ Oct:10 / Nov:11/  Dec;12

Example:  Month/Year   Oct/1978 =  10/1978

11.
Ethnicity

12.
What is your marital status? 
Single
Co-Habiting
Married
Separated
Divorced
Widowed

These last questions will relate to children living at home.

13.
Do you have any children living at home

Please indicate Gender (M/F)
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6
Please indicate:
Gender: Male =M  /  Female=F

14.
Now for each child indicate their date of birth.
MONTH: Jan: 1/Feb: 2/Mar: 3 /Apr: 4/May: 5/ June: 6 Jul: 7/ Aug: 8/ Sep: 9/ Oct:10 / Nov:11/  Dec:12
DAY:  1-31
YEAR:  Last Numbers   2012=12    1987=87

For example: Born October 8, 1995 =  10/8/95
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6
Please indicate:
Birth date




OFFICE USE ONLY