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
 Male Female

Date of Birth:

Age:

How Did Your Hear About Us?

CONTACT INFORMATION

Cell Phone:

Is Your Mobile Device a Smartphone?
 Yes No

Home Phone:

Email

I Presently:
 Own My Home Rent My Home Live With Family

Address:

City, State, Zip:

Parish:

RACE

 African American/Black Caucasian/White Hispanic/Latino Asian Middle Eastern Pacific Islander Native American/Alaskan Other (please specify below)

Do You Speak Any Foreign Languages?
 Yes No

If Yes, Please List:

MARITAL STATUS

 Single, Never Married Married Separated/Divorced Widowed Living With Partner
 NO, I do not have children under the age of 18 in my home YES, I have children under the age of 18 in my home

EMPLOYMENT and EDUCATION

 Full-time Part-time Unemployed Self-Employed Homemaker Retired Disabled Student (please list major below)

Completed Education:
 Grade school or less Attended high school High school graduate or GED Attended vocational / Technical School Completed vocational / technical school Attended college College graduate (Associate's) College graduate (Bachelor's) Attended grad school Master's Degree Doctoral Degree Professional 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 Louisiana I am NOT a registered voter in the State of Louisiana

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

 Democrat Republican Independent Other (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.
 Acne ADHD Allergies Alzheimer's Angina Anxiety Arthritic/Rheumatoid Arthritis Arrhythmia Asthma Baldness/Thinning Hair Bladder Control/Incontinence Bleeding Gums/Gingivitis Blindness/Visual Impairment Breast Cancer Cancer Chronic Back Pain Chronic Bronchitis Chronic Ear Infections Clinical Depression Congestive Heart Failure (CHF) Diabetes Diabetes Type 1 Diabetes Type 2 Dialysis Eczema Eczema/Psoriasis Emphysema Enlarged Prostate Epilepsy Estrogen Replacement Therapy Frequent Headaches Frequent Heartburn Gastritis GERD Headaches Hearing Difficulty Heart Disease Hemorrhoids Hemophilia Hepatitis A,B,C High Blood Pressure High Cholesterol HIV/AIDS Impotence/E.D. Insomnia Irritable Bowel Syndrome Menopause Migraines Multiple Sclerosis Osteoporosis Parkinson's disease Physical Handicap PMS PPMD Premature Ejaculation Prostate Cancer Psoriasis Sinusitis Spinal Cord Injury Staph Infection STDs Surgical Implants Tumors Ulcers Yeast 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

Sign up for Newsletter

 
* = required field