All of the data gathered in this form will remain strictly confidential. Focus Group Testing DOES NOT sell any information to third parties such as mailing list providers. Information provided is used solely as a guide to contact you for paid focus groups and interviews.

Please answer the following questions so we can accurately place you in future focus groups.

SECTION A: PERSONAL & BUSINESS INFORMATION

Name

Gender
MaleFemale

Date of Birth:

Age:

How Did Your Hear About Us?

CONTACT INFORMATION

Cell Phone:

Is Your Mobile Device a Smartphone?
YesNo

Home Phone:

Email

I Presently:
Own My HomeRent My HomeLive With Family

Address:

City, State, Zip:

Parish:

RACE

African American/BlackCaucasian/WhiteHispanic/LatinoAsianMiddle EasternPacific IslanderNative American/AlaskanOther (please specify below)

Do You Speak Any Foreign Languages?
YesNo

If Yes, Please List:

MARITAL STATUS

Single, Never MarriedMarriedSeparated/DivorcedWidowedLiving With Partner
NO, I do not have children under the age of 18 in my homeYES, I have children under the age of 18 in my home

EMPLOYMENT and EDUCATION

Full-timePart-timeUnemployedSelf-EmployedHomemakerRetiredDisabledStudent (please list major below)

Completed Education:
Grade school or lessAttended high schoolHigh school graduate or GEDAttended vocational / Technical SchoolCompleted vocational / technical schoolAttended collegeCollege graduate (Associate's)College graduate (Bachelor's)Attended grad schoolMaster's DegreeDoctoral DegreeProfessional Degree

Total Household Income Before Taxes
Less than $25,000$25,000 - $50,000$50,000 - $75,000$75,000 - $100,000$100,000 - $150,000$150,000 or more

Name of Company

Occupation

Industry:

VOTER

Please choose one below
I am a registered voter in the State of LouisianaI am NOT a registered voter in the State of Louisiana

Please list the City/Parish in which you are registered to vote:

DemocratRepublicanIndependentOther (please list below)

SECTION B: ADDITIONAL DEMOGRAPHIC INFO & PRODUCT USAGE

Medical Research: We are regularly seeking respondents with various health conditions and ailments for medical related studies such as new drugs and alternative therapies. If you are comfortable discussing health conditions and interested in participating in these types of studies, please check any ailments that apply below.
AcneADHDAllergiesAlzheimer'sAnginaAnxietyArthritic/RheumatoidArthritisArrhythmiaAsthmaBaldness/Thinning HairBladder Control/IncontinenceBleeding Gums/GingivitisBlindness/Visual ImpairmentBreast CancerCancerChronic Back PainChronic BronchitisChronic Ear InfectionsClinical DepressionCongestive Heart Failure (CHF)DiabetesDiabetes Type 1Diabetes Type 2DialysisEczemaEczema/PsoriasisEmphysemaEnlarged ProstateEpilepsyEstrogen Replacement TherapyFrequent HeadachesFrequent HeartburnGastritisGERDHeadachesHearing DifficultyHeart DiseaseHemorrhoidsHemophiliaHepatitis A,B,CHigh Blood PressureHigh CholesterolHIV/AIDSImpotence/E.D.InsomniaIrritable Bowel SyndromeMenopauseMigrainesMultiple SclerosisOsteoporosisParkinson's diseasePhysical HandicapPMSPPMDPremature EjaculationProstate CancerPsoriasisSinusitisSpinal Cord InjuryStaph InfectionSTDsSurgical ImplantsTumorsUlcersYeast Infection

Other Unlisted Conditions: (please list the MEDICAL CONDITIONS ONLY, no specifics or descriptions are necessary.)

Please list any prescription medications you are currently taking:

SECTION C: REFER A FRIEND OR FAMILY MEMBER

Do you know anyone else who would be interested in participating with research as you did?
Referral #1:
Name:
Phone:
Email:
Referral #2:
Name:
Phone:
Email:
Referral #3:
Name:
Phone:
Email:
Referral #4:
Name:
Phone:
Email:
Referral #5:
Name:
Phone:
Email:

About Us

 

Focus Group Testing, located in downtown New Orleans, is a state-of-the-art, full-service facility offering comprehensive services to clients nationwide. Located in the heart of New Orleans, the facility sits adjacent to the French Quarter, Central Business District and Riverfront. It is just minutes away from the Convention Center.

Contact Info

 

Business Inquiries
[email protected]
504.558.1820

Recruiting and General Info
[email protected]
504.571.6350

Address:
365 Canal Street Suite 1760 New Orleans, LA 70130