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Focus Group Participant Registration

Guinea Pig

Your registration as a potential focus group participant will allow us to contact you regarding future opportunities. Answers to just 23 quick questions included in the registration, will help us to determine which research studies would benefit from your participation. Your identity will remain anonymous, and contact information is always kept confidential. Both are used solely by Practical Strategies, Inc., so that we are able to communicate with you and match participants to the requests of our clients. We invite you to contact us at anytime with questions and to share this opportunity with friends, family, and colleagues who might like to participate in focus groups. Thank you for your time and interest. We hope for an opportunity to work with you in the near future!

* First Name:

* Last Name:

* Email Address:

* Address:

Address (cont'd):

* City:

* State:

* Zip:

* Home Phone:

Cell Phone:

* Gender:
Male
Female

* In what year were you born?

* What is the highest level of education you have completed?
Grade school or less
Some high school
High school graduate
Vocational, trade school, or technical training beyond high school
Some college
College graduate
Post-graduate studies or degree (beyond college degree)
Professional degree

* How would you describe your current employment status?
Employed full-time
Employed part-time
Self-employed
Retired
Unemployed
Other

* Which of the following best describes your occupation?
Executive / Managerial / Owner
Salesperson / buyer
Professional / technical
Clerical / administrative
Warehouse / trade / construction
Homemaker
Student
Other

* What is your own yearly gross income?
Under $25,000
$25,000 to under $35,000
$35,000 to under $45,000
$45,000 to under $55,000
$55,000 to under $75,000
$75,000 to under $100,000
Over $100,000

* What is your total household income, including all earners in your household?
Under $25,000
$25,000 to under $35,000
$35,000 to under $45,000
$45,000 to under $55,000
$55,000 to under $75,000
$75,000 to under $100,000
Over $100,000

* What is your current marital status?
Single (never been married)
Married
Separated
Widowed
Divorced
Domestic Partner

* What is your religious affiliation?
Protestant
Catholic
Mormon
Jewish
Muslim
Hindu
Agnostic or Atheist
Other (please specify)

* What is your ethnicity?
Caucasian
African-American
Hispanic or Latino
Asian / Pacific Islander
Middle Eastern
Native American
Other (please specify)

* Do you rent or own your home?
Rent
Own
Other

* Do you have children?
Yes
No

If yes, ages?

* Political Affiliation
Democrat
Republican
Independent
Green
Other (please specify)

All fields marked with a * are required.