First Name: Last Name: Address: City: State: Zip Code: Country: Phone Number: Email Address: 1. Have you ever participated in an online survey or focus group? Choices Yes No 2. Gender Choices Female Male 3. What is your age range? Choices 18-29 30-39 40-49 50-59 60-69 70+ 4. What is your martial status? Choices Single Married Divorced Separated Widowed 5. Do you have children? Choices Yes No 6. What are your interests? Outdoor Sports Select if applicable Yes Arts/Crafts Select if applicable Yes Travel/Leisure Select if applicable Yes Reading/Writing Select if applicable Yes Dining Out Select if applicable Yes Watch TV/Movies Select if applicable Yes Computers Select if applicable Yes Home Improvement Select if applicable Yes Video Games Select if applicable Yes Other (please specify) 7. Where do you access the internet? (Check all that apply) Work Select if applicable Yes Home Select if applicable Yes School Select if applicable Yes Library Select if applicable Yes Other (please specify) 8. How often do you access the internet? Choices Daily 2-3 times per week Weekly 2-3 times per month Once a month or less 9. What kind of computer do you have? Windows Select if applicable Yes Macintosh Select if applicable Yes Other (please specify) 10. How many computers are in your household? Choices None One Two Three or more 11. Have you ever made a purchase on the internet? Choices Yes No 12. What field do you work in? Choices Computers Education Advertising Student Health Care Child Care Law Government Agriculture Retail Financial Industry Public Relations Other 13. What is your position? Choices Middle Management Executive Self employed Marketing/Sales Artist/Designer Programmer Teacher/Instructor Clerical Customer Service Other 14. What is your highest level of education? Choices Grammar school or less High School graduate or less Some college College graduate Graduate school Other 15. What is your income range? Choices Under $24,999 $25,000-$39,999 $40,000-$54,999 $55,000-$69,999 $70,000-$84,999 $85,000-$99,999 $100,000+ 16. Who were you referred by? Name: Email: 17. What is your ethnic background? Choices Caucasian African-American Asian Hispanic Native-American Indian Other Back to Top
1. Have you ever participated in an online survey or focus group? Choices Yes No
2. Gender Choices Female Male
3. What is your age range? Choices 18-29 30-39 40-49 50-59 60-69 70+ 4. What is your martial status? Choices Single Married Divorced Separated Widowed 5. Do you have children? Choices Yes No
6. What are your interests?
7. Where do you access the internet? (Check all that apply)
8. How often do you access the internet? Choices Daily 2-3 times per week Weekly 2-3 times per month Once a month or less
9. What kind of computer do you have?
10. How many computers are in your household? Choices None One Two Three or more 11. Have you ever made a purchase on the internet? Choices Yes No
12. What field do you work in? Choices Computers Education Advertising Student Health Care Child Care Law Government Agriculture Retail Financial Industry Public Relations Other
13. What is your position? Choices Middle Management Executive Self employed Marketing/Sales Artist/Designer Programmer Teacher/Instructor Clerical Customer Service Other 14. What is your highest level of education? Choices Grammar school or less High School graduate or less Some college College graduate Graduate school Other 15. What is your income range? Choices Under $24,999 $25,000-$39,999 $40,000-$54,999 $55,000-$69,999 $70,000-$84,999 $85,000-$99,999 $100,000+
16. Who were you referred by? Name:
Email:
17. What is your ethnic background? Choices Caucasian African-American Asian Hispanic Native-American Indian Other
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