We are currently looking for males and females of all ages to participate in consumer research studies.  Your opinion is very important to us.  We will pay you for your time when you participate in one of our round table discussions, in-depth one-on-one interviews, or product usage studies.
 
It’s easy and fun.  You can voice your opinion on a variety of new products or services while making money.  If you are interested, please take a few moments to fill out this questionnaire.  After receiving your completed questionnaire, we will be calling you to see if you qualify to participate in upcoming studies, interviews, or group discussions.
 
We look forward to having you as a participant.  Various Views Research is a marketing research company and no attempt will be made to sell goods or services.  All information received from you and other valued respondents is kept strictly confidential and is used for classification purposes only.  Should you wish to be removed from our database, you only need to contact us.  We hope to be calling you soon!

ADULT MALE

Name:
Date of Birth:
Current Employment Status (please select one)
Full-time
Part-time
Non working
Retired

Company Name:
Type of Business:
Position:
Work Number:
Cell Number:
Email:
Would you like to receive email regarding future studies?
Yes
No

Please select the the appropriate answer in each category below


Race
Marital Status
Caucasian
African-American
Asian
Hispanic
Bi-Racial
Native American
Other
Divorced/Separated
Married/Living with Other
Single
Refused
Widowed

Education
Party Affiliation
Grade School
Some High School
High School Graduate
Some College
College Graduate
Post Graduate
Other
Democrat
Republican
Independent
Unknown/Refused

ADULT FEMALE

Name:
Date of Birth:
Current Employment Status (please select one)
Full-time
Part-time
Non working
Retired

Company Name:
Type of Business:
Position
Work Number:
Cell Number:
Email
Would you like to receive email regarding future studies?
Yes
No

Please select the the appropriate answer in each category below


Race
Marital Status
Caucasian
African-American
Asian
Hispanic
Bi-Racial
Native American
Other
Divorced/Separated
Married/Living with Other
Single
Refused
Widowed

Education
Party Affiliation
Grade School
Some High School
High School Graduate
Some College
College Graduate
Post Graduate
Other
Democrat
Republican
Independent
Unknown/Refused



OTHER ADULT (18+) MALE (if applicable)

Name:
Date of Birth:
Current Employment Status (please select one)
Full-time
Part-time
Non working
Retired

Company Name:
Type of Business:
Position:
Work Number:
Cell Number:
Email:
Would you like to receive email regarding future studies?
Yes
No

Please select the the appropriate answer in each category below


Race
Marital Status
Caucasian
African-American
Asian
Hispanic
Bi-Racial
Native American
Other
Divorced/Separated
Married/Living with Other
Single
Refused
Widowed

Education
Party Affiliation
Grade School
Some High School
High School Graduate
Some College
College Graduate
Post Graduate
Other
Democrat
Republican
Independent
Unknown/Refused

OTHER ADULT (18+) FEMALE (if applicable)

Name:
Date of Birth:
Current Employment Status (please select one)
Full-time
Part-time
Non working
Retired

Company Name:
Type of Business:
Position:
Work Number:
Cell Number:
Email:
Would you like to receive email regarding future studies?
Yes
No

Please select the the appropriate answer in each category below


Race
Marital Status
Caucasian
African-American
Asian
Hispanic
Bi-Racial
Native American
Other
Divorced/Separated
Married/Living with Other
Single
Refused
Widowed

Education
Party Affiliation
Grade School
Some High School
High School Graduate
Some College
College Graduate
Post Graduate
Other
Democrat
Republican
Independent
Unknown/Refused




Address of Household:
City: State: Zip:
Home Phone: County:
Beast way to reach you
Home Number
Cell Number
Work Number

If expecting or adopting, due date or date of birth: Male Female Unknown
Please mark for all children (under 18) currently living in your household
Name: Date of Birth: Male Female
Name: Date of Birth: Male Female
Name: Date of Birth: Male Female
Name: Date of Birth: Male Female
Name: Date of Birth: Male Female
Name: Date of Birth: Male Female

Housing Type
(please select one)
Apartment
Condominium
House
Mobile Home
Other
Refused

Household and Personal Care Products
Please select the gender of the household member who has used the product in the past 6 months.  Leave blank if not used.
Adult Male
Adult Female
Other Adult Male
Other Adult Female





Air Freshener




Alcohol




Allergy Products




Antacids




Breath Spray/Strips




Bulk Fiber




Cigarettes




Coffee - Ground Regular




Coffee - Instant Regular




Coffee - Specialty




Denture Adhesive




Denture Cleaner




Automatic Dish Detergent - Liquid Gel




Automatic Dish Detergent - Powder




Dusting / Mitts / Wipes / Wands




Fabric Refresher




Fabric Softener - Dryer Sheet




Fabric Softener - Liquid




Floss - Manual String




Floss - Dental Picks




Home Dry Cleaning Products




Laundry Detergent - Liquid




Laundry Detergent - Powder




Laxatives




Mopping Systems - Dry




Mopping Systems - Wet




Mopping Systems - Rechargable




Mouthwash




Shaver - Electric




Shaver - Manual




Teeth Whitening Products




Water Filtration Systems - Faucet




Water Filtration Systems - Pitcher




Water Filtration Systems - Refrigerator




Water Filtration Systems - Under Sink




Water Filtration Systems - Whole House

Facial and Body Products
Please select the gender of the household member who has used the product in the past 6 months.  Leave blank if not used.
Adult Male Adult Female Other Adult Male Other Adult Female




Beauty Bar Soap




Beauty Body Wash




Deodorant Bar Soap




Deodorant Body Wash




Body Lotion




Facial Cleanser




Facial Moisturizer




Anti-Aging Products

Feminine Protection Products
Which of the following best describes the femini protection usage in your household during the menstrual cycles?
Adult Female Other Adult Female


Pads Only


Monstly Pads, Some Tampons


Pads and Tampons Equally


Mostly Tampons, Some Pads


Tampons Only
What size and brands of protection products are used by females in your household.
Adult Female Other Adult Female Size of Pads


Regular


Ultrathin


Maxi/Thick


Super/Long


Brands of Pads


Alwaysョ


Kotexョ


Stayfreeョ


Store Brand


Brands of Tampons


OBョ


Tampaxョ


Kotexョ


Playtexョ


Store Brand


Brands of Pantiliners


Alwaysョ


Kotexョ


Carefreeョ


Store Brand


Incontinence Products
Please select the gender of the household member who has used the product in the past 6 months.  Leave blank if not used
Adult Male Adult Female Other Adult Male Other Adult Female




Feminine Pads




Feminine Liners




Incontinence Pads/Liners




Incontinence Underwear

Hair Care Products
Please select the gender of the household member who has used the product in the past 6 months.  Leave blank if not used
Adult Male Adult Female Other Adult Male Other Adult Female




2 in 1 Shampoo and Conditioner




Value Brand Shampoo
(i.e. Suave, V05, White Raind, etc.)




Average Brand Shampoo (i.e. Herbal Essences, Tressemme, Fructis, etc.)




Premium Brand Shampoo
(i.e. Pantene, Dove, Vive, etc.)




Dandruff Shampoo




Salon Brand Shampoo (ie. Matrix, Paul Mitchell, Redken, etc.)




Value Brand Conditioner
(i.e. Suave, V05, White Raind, etc.)




Average Brand Conditioner (i.e. Herbal Essences, Tressemme, Fructis, etc.)




Premium Brand Conditioner
(i.e. Pantene, Dove, Vive, etc.)




Home Hair Coloring Products




Highlighting Products




Other Types of Hair Care Products such as Mousse, Gel, Hairspray, Spritz, Wax, etc.

Health Care Devices
Please select the gender of the household member who has used the product in the past 6 months.  Leave blank if not used
Adult Male Adult Female Other Adult Male Other Adult Female




Contacts - Hard




Contacts - Soft




Eyeglasses - Single




Eyeglasses - Bi-focals




Eyeglasses - Tri-focals




Glucose Meter




Toothbrushes - Battery




Toothbrushes - Electric




Toothbrushes - Manual

Health Conditions
Has anyone in your household been diagnosed with any of the following?  Please select the appropriate box.
Adult Male Adult Female Other Adult Male Other Adult Female




Acid Reflux




Allergies




Arthritis - Osteo




Arthritis - Rheumatoid




Asthma




Back, Neck, Knee Pain




Cancer




Colitis




Constipation




Depression




Diabetes - Type I




Diabetes - Type II




Diabetes - Unknown Type




Eczema




Erectile Dysfunction




Fibromyalgia




Gas/Upset Stomach




Heart Disease




Hemorrhoids




High Cholesterol




HIV/AIDS




Human Growth Hormone Deficiency




Hypertension




Incontinence




Irritable Bowel Syndrome




Pre-Menopausal




Post-Menopausal




Regular Monthly Menstrual Periods




Menstrual Cramps




Migraines




Osteoporosis




Psoriasis




Rosacea




Sensitive Teeth




Sinus




Ulcers




Urinary Tract Infection




Yeast Infection

Electronics
Please indicate any of the following items that you have in your household. Please check all that apply.

Cellular Phone

Computer

Dishwasher

Internet Access

Pet Foods
If you own a dog or cat, what type of food do you feed them?

Dry Dog Food - Value

Dry Dog Food - Average

Dry Dog Food - Premium

Can Dog Food - Value

Can Dog Food - Average

Can Dog Food - Premium

Dry Cat Food - Value

Dry Cat Food - Average

Dry Cat Food - Premium

Can Cat Food - Value

Can Cat Food - Average

Can Cat Food - Premium

Where do you shop?  Please check all that apply.

Kmart™

Walmartョ

Targetョ

Walgreensョ

CVS/pharmacyョ

Meijerョ

Krogerョ

Bigg'sョ

Sam's Clubョ - Business Membership

Sam's Clubョ - Consumer Membership

Costcoョ - Business Membership

Costcoョ - Consumer Membership

Dollar Stores (i.e. 99「enter, Dollar Treeョ, etc.)

Dollar Generalョ

Family Dollarョ

Coffee Shops (i.e. Starbucksョ, Caribou Coffeeョ, etc.)

Convenience Stores

Where do you usually purchase your personal care products?  Please check all that apply.


Department Store (i.e. Macy'sョ, Dillardsョ, etc.)

Grocery Store(i.e. Krogerョ, Meijerョ, Bigg'sョ, etc.)

Mass Merchandiser (i.e. Wal-Martョ, Kmart™, Targetョ, etc.)

Drug Store (i.e. CVS/pharmacyョ, Walgreensョ, etc.)

Specialty (i.e. Bath & Body Worksョ, Sephoraョ, etc.)

Club Store (i.e. Samsョ, Costcoョ, etc.)

Dollar Stores (i.e. 99「enter, Dollar Treeョ, etc.)

The Following is for Classification Purposes Only
What is your total family income, before taxes?
Check the appropriate answer.
Under $20,000
$20,000 to $29,999
$30,000 to $39,999
$40,000 to $49,999
$50,000 to $59,999
$60,000 to $69,999
$70,000 to $79,999
$80,000 to $99,999
$100,000 and over


Who is the primary shopper?
Please check one.
Adult Male
Adult Female
Other Adult Male
Other Adult Female
Equal


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