We do require that Respondents live or work within approximately 50 miles of The Galleria area and you MUST have a working local telephone number. |
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| Do you live in: |
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| Do we have your permission to contact you regarding upcoming research studies to determine your interest and to see if you fit the criteria required for a specific study? |
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CONTACT INFORMATION |
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| First Name:* |
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| Last Name:* |
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Home Phone #: |
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| Work Phone #: |
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| Cell Phone #: |
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| Alt #: |
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| E-Mail address:* |
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| Preferred method of contact: |
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ABOUT YOUR HOME |
Home Street Address (Include apt #):
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City:
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State:
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Zip Code:
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County: |
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| Type of Dwelling: |
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| Do you currently? |
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ABOUT YOU |
Your Employment Status |
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Are you currently? |
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| Your Occupation (current /or most recently held) |
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| Industry You Work In? |
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| Job Title: |
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| Name of your employer? |
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| Zip Code of your Office: |
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| Your gender? |
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| Date of Birth: |
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| Highest Education Attained |
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| Your Ethnicity or Heritage |
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| Your Marital Status |
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| Your Political Philosophy |
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| Are you registered to vote? |
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| Your Party Affiliation - Voter Registration |
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| Statements that Describe May or May Not You |
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| For each statement, indicate if it describes you a lot, a little, or does not describe you |
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| I would rather hear what others have to say than express my own opinion |
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| I frequently try out new products and services before my friends do |
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| I would make an effort to attend a two-hour discussion to share my thoughts and opinions on topics of interest to me |
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| Asking their customers, like me, is a good way for companies to improve their products and services |
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ABOUT FAMILY MEMBERS LIVING AT HOME |
Do you have a Spouse, Significant Other, or other adult living in the household that would also like to become a Research Panelist? |
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GENDER AND DATE OF BIRTH OF CHILDREN |
| Do you have children in the household? |
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| Please answer for your oldest Child Under 18, then the next oldest child, etc, we can accept up to 6 children. |
| Child 1 - Gender |
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| Child 1 - Date of Birth |
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| Child 2 - Gender |
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| Child 2 - Date of Birth |
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| Child 3 - Gender |
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| Child 3 - Date of Birth |
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| Child 4 - Gender |
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| Child 4 - Date of Birth |
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| Child 5 - Gender |
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| Child 5 - Date of Birth |
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| Child 6 - Gender |
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| Child 6 - Date of Birth |
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INDIVIDUAL AND FAMILY LIFESTYLE / INTERESTS |
Does this describe you or anyone else in your household?
Please check all that apply.
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INDIVIDUAL AND FAMILY HOBBIES AND LEISURE ACTIVITIES |
Please indicate if any of the following are of interest to you or other family members. Please check all that apply.
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INDIVIDUAL AND FAMILY MUSIC PREFERENCES |
Genres or styles of music you and other family members listen to regularly. Please check all that apply.
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INDIVIDUAL AND FAMILY CHRONIC MEDICAL CONDITIONS OR DISEASE |
We conduct all manner of different medical research studies, ranging from minor conditions such as allergies up to major conditions such as heart disease or cancer. Do you or any member of your household happen to have any of the following medical conditions or diseases? Please check all that apply.
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| Cancer |
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| Heart Disease |
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| Respiratory |
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| Neurological/Mental Health |
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| Auto-Immune Diseases |
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| Endocrine |
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| Gastrointestinal Disorders |
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| Arthritis/ Bone / Joint |
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| Other |
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HOUSEHOLD INCOME |
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Please select the range that best represents your total household income from last year? |
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| Please enter the anti spam code: |
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