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Respondent Form

Thank you for your interest in becoming a participant in consumer research and focus group studies. Our first step is to gather some basic information from you regarding product usage. Below is a list of questions that will only take minutes to answer. Our focus group facility is located on 6910 North Shadeland Avenue. The information collected will only be used by Walker Research and will not be given out to any third parties. When a study comes up that you potentially qualify for, you will be contacted. Please feel free to share this with anyone who you might think will be interested in future studies. Until then, thank you, once again, for your interest in our studies. Your opinions are important to us!

If you have any questions please email us at focusgroup@walkerinfo.com.

First Name:

Last Name:

E-mail:

Home Phone:

Gender:

Male Female

Date of Birth:

Address:

City:

State:

Zip Code:

Ethnic Background:

African American
Asian
Hispanic
Native American
White
Other (Please specify)

Marital Status:

Married
Single
Divorced
Separated
Widowed

Education:

Less than HS Grad
High Grad
Some College
Tech School
College Grad
Graduate Degree

Housing:

Own
Rent
Live with Parents
Other (Please specify)

Household Income:

Under $20,000
$20,000 - 29,999
$30,000 - 39,999
$40,000 - 49,999
$50,000 - 59,999
$60,000 - 69,999
$70,000 - 79,999
$80,000 - 99,999
$100,000 - 149,999
Over $150,000

Employment:

Full Time
Part Time
Not Employed
Retired

If employed what is your occupation
(position and type of business)

If applicable, what is your spouse’s occupation
(position and type of business)

Please list the Date of birth and Gender of each child living at home, if applicable?
1.
2.
3.
4.
5.

Which of the following, if any, do you suffer from?
Allergies
Arthritis
Asthma
Dandruff
Diabetes
            Type 1
            Type 2
            Glucose Monitor     Type:
Fibromyalgia
High Cholesterol
High Blood Pressure
Migraine Headaches
Heartburn at least once a week
Overactive Bladder or OAB

Which of the following products do you use on a regular basis?
Antacids-liquid
Antacids-tablets
Blood Thinners
Bulk Fiber Laxatives
Other Laxatives
Cigarettes
Cigars, Pipes
Contact Lens
Eye Glasses
Dentures

What brand of the following, if any, do you use most often?

Toothpaste:
Mouthwash:
Beer:
Soft Drink:
Coffee:
Diapers:
Laundry Detergent:
	Is that . . . Liquid Powder

Pets
Dog Food Food:
Cat Food Food:

What brands of the following, if any, do you own?

Digital Video Recorder:
DVD Player:
High-Defnition Television:
Digital Camera:
MP3 Player:
Notebook Computer:
Dishwasher:
Over the Range Microwave:
Refrigerator:
Stove/Oven:
Clothes Washer:
Clothes Dryer:

Who, if anyone supplies the following?

Internet Provider:
Cell Phone Provider:
Cable/Satellite Provider:
Satellite Radio:

What grocery store do you shop at most often?

What radio stations do listen to?

What television station do you watch most often for local news?

What is the year/make/model of the vehicle you drive most often?

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