JOIN OUR DATABASE     

SECTION A -- Personal & Household Information

Please fill out the form as completely as possible. 

1. How did you find us / Who referred you?
   
   Another Website (Please specify below)
   Bay Area Parent
   Bay GuardianBlog (Please specify which below)Craig's ListEast Bay ExpressEmail from us or a friendExaminerFacebookFlyerFriend/Family Member/Co-WorkerFrom an employee of Fleischman (Please specify below)From an Organization or School (Please specify below)MyspaceNoe Valley VoiceSFGate.comSF Gator (SFSU Newspaper)SF WeeklyValpac Mailer

   Please Specify Referral, Website, School, Organization or Employee:
   

    
2. What is your name, address & phone number?

   First Name	MsMr
   Last Name 	
   
   Street		
   City  	 	
   Zip Code		
   
   	      	          Ex:    415	  398-4140      
   Home Phone Number  	 
   
   Work Phone Number   	 
   
   Cell Phone Number   	  
   
    From time to time, we send out advance notice of upcoming groups via text message.
   Click here if you would like to receive these notifications. Please be assured that we
   will ONLY send you information about future marketing research sessions with FFR.
   
   
   More often, we send out advance notice of upcoming groups via email.
   To facilitate this, we ask that you provide us with an email address.
   Please be assured that we will only use this information to get in touch about
   marketing research sessions with FFR.
   
   Email Address	
   

3. What is your birthdate? (Please be honest as it is
   very important for demographic purposes.)
   
   (Please list in this format: MM/DD/YYYY
   Example: 09/09/1940 - NO PERIODS OR SPACES)
   
   
   

4. What is your marital status?:
   
   SingleMarriedDivorcedSeparatedWidowed
   

5. What is your current living situation?
   
   Live Alone Live with Spouse Live with Significant Other Live with Roommate(s) Live with Parent(s) Live with Family (not parents)
   
   
6. Last education level completed?
   
   Please Select Some High School High School Graduate Some College Associate Degree (AA) College Graduate (BA, BS) Some Graduate School Graduate Degree (MA, MS) Some Post Graduate Post Graduate Degree (PhD)
   
   

7. What is your ethnic background?
   
   African AmericanAsianCaucasianHispanic/LatinoFilipino / Pacific IslanderNative AmericanOther
   

8. Do you own or rent your current residence?
   
   Own	Rent

9. Who is your Long Distance Telephone provider?
   
   
   

10. Do you have children? What is/are their birthdate(s) & gender(s)?
    
    (Please enter birthdate(s) in the same format as above. Example: 12/25/1980)
    
    Birthdate Gender N/A Male Female Name (optional)
    Birthdate Gender N/A Male Female Name (optional)
    Birthdate Gender N/A Male Female Name (optional)
    
    
11. Please tell us which income range best describes your total annual household income?
    This information is very important for demographic purposes
    and will remain absolutely CONFIDENTIAL.
    
    Less than $10,000 $10,000 - $20,000 $20,000 - $30,000 $30,000 - $40,000 $40,000 - $50,000 $50,000 - $60,000 $60,000 - $70,000 $70,000 - $80,000 $80,000 - $90,000 $90,000 - $100,000 $100,000 - $150,000 $150,000 - $200,000 $200,000+ Refused
    
    
12. 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 type 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:

     

Back to Top

SECTION B -- Product Usage

This section simply asks what products you own or consume.

1. Do you drink alcoholic beverages? (Check all that apply):
   
   Non-Drinker Beer Wine Vodka Scotch Cognac Rum
   Gin Brandy
   
   
2. What are your favorite radio stations? List up to four in the spaces provided.
   (Please list call letters, if possible.) 
   
   Ex: KLLC           KITS
   
   
   
3. Do you use credit cards?  (Check all that apply):
   
   Visa MasterCard American Express Discover
   
   
4. Do you own a motor vehicle? What is the year, make and model?
   List up to two vehicles in the spaces provided:
   
   Ex: 2001 Ford Expedition            Ex: 2000 Toyota Camry
   
   
   
5. Do you own a home computer or Video Game System? What type and what other accessories do you own?
   (Check all that apply):
   
   IBM or compatible Desktop
   IBM or compatible Laptop or Notebook
   Apple Macintosh or compatible Desktop
   Apple Macintosh or compatible Laptop or Notebook
   
   PDA (Palm, PocketPC, etc) Internet Access Cellular Phone
   Digital Camera
   
   Nintendo DS Nintendo GameCube  Nintendo Wii Sony PS2  Sony PS3
   Sony PSP   Xbox Xbox 360   PC Games
   
   
6. We have offices in downtown San Francisco and Walnut Creek. Are you able to attend groups at our San Francisco office, Walnut Creek office or Both? (PLEASE NOTE: In general, our focus groups and participation are limited to the San Francisco Bay Area.)
   
   San Francisco Office Walnut Creek Office Both SF and WC offices
   
   
7. We do groups and interviews during the day and in the evening after working hours.
   Our groups normally last no longer than two hours and you may always decline
   to attend if a specific group/interview does not meet your schedule.
   
   Are you able to attend: ?
   
   Day groups Evening groups Both Day and Evening groups
   
   

Back to Top

SECTION C -- Business Information

We also do many business-related studies that ask your opinions about topics such as computers, software and business travel. Please fill out as completely as possible.

1. What is your primary occupation / job title?

2. Do you work full time, part time or are you not working currently?:
   
   Full Time Part Time Not Working (Student/Retired)
   
   
3. Who is your primary employer (Students: Tell us your school.)? (If applicable):
   
   
   
   
4. In what industry is the company involved? (Many companies may fit into more
   than one category, but please choose what the company PRIMARILY does. 
   So if you work at a Pharmacy for example, please select 'Retail' rather than 'Pharmaceuticals'.)
   (If applicable):
   
   Not Applicable Advertising, Marketing, Public Relations Architecture/Engineering Arts & Entertainment Business Services Computer Services Computer Technology/Electronics/Software Construction Consulting Consumer Services Distribution Education Financial (Banks, Investment, Accounting) Food Industry (Restaurant, Catering, Manuf, Distrib) Government (Law Enforcement, City, County, Federal) Hospitality (Hotel, Tourism, Travel) Internet (Graphic Design, Web Design, Dot Com) Import/Export Insurance Legal Manufacturing Media (TV, Radio, Newspaper, Magazine, Publishing) Medical (Hospital, Health) Non-Profit (Social Services - Non-Govt) Pharmaceuticals (Biotech, Drugs) Real Estate/Property Management Retail Telecommunications/Cellular Temporary or Personnel Services Transportation (Taxi, Airline, Train) Utilities (Electricity, Gas, Water) Wholesaling Other
   
   
5. Approximately, how many people are employed for the company WORLDWIDE?
   (Your best estimate is fine.) (If applicable):
   
   Not Applicable 1 2-10 11-50 51-100 101-250 250-500 500-1000 1000-5000 5000+
   
   
6. Do you use a computer at work? What type and what accessories do you use?
   (Check all that apply)
   
   IBM or compatible Desktop
   IBM or compatible Laptop or Notebook
   Apple Macintosh or compatible Desktop
   Apple Macintosh or compatible Laptop or Notebook
   
   PDA (Palm, PocketPC, etc) Internet Access Cellular Phone
   Digital Camera
   
   
7. Do you travel domestically or internationally for business purposes?
   If so, how many times in a year (on average)? (Record number)
   
   Domestic Travel Not Applicable Once a year 2-4 times a year 5-10 times a year 11-50 times a year More than 50 times a year  
   International Travel Not Applicable Once a year 2-4 times a year 5-10 times a year 11-50 times a year More than 50 times a year
   
   
8. What is your business address and fax number? (If applicable):

   Street		
   City  	 	
   Zip Code		
   
   Work Fax Number 	 
   
   
   
   
   
   You're Finished!  Please move to the submission section below.
   

Back to Top

FORM SUBMISSION

We appreciate your interest in our research groups and look forward to speaking with you.
Thanks again!

Back to Top