Adult Survey

Please complete the following survey for each adult interested in becoming a panelist for Innovation Research. All information will be used internally by Innovation Research and will be maintained in a confidential manner. * indicates required field *Referred by Referred by: Telephone Telephone: ()- *First Name *First Name: *Last Name *Last Name: *Address 1 *Address 1: Address 2: *City *City: *State *State: -Select- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming *ZIP *ZIP: E-Mail: *Date of Birth: -Select- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec ... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 -Select- 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 *Gender: Male Female *Primary Telephone: ()- with areacode (Note: This must be a direct line where we can reach you or leave a recorded message without going through a receptionist, menu, or switchboard, or using an extension.) Alternate Telephone: ()- with areacode (Note: This is a number where our staff could reach you during business hours if needed.   There are no restrictions about extensions or switchboards for this number.  This may be the same as your primary number.) *Do you have any known food allergies? No Yes If Yes, state allergies: *How did you hear about us? *How did you hear about us?: -Select- College Campus or Event Craigslist Word of Mouth (family, friends, etc) Facebook HyVee Receipt Flyer Omaha Royals Game Other Other: If Other: *Do you adhere to a medically prescribed, strict religious or otherwise restricted diet?   Yes   No *Which of the following options are you available for testing?                     (Check all that apply) Daytime (8:00am – 4:00pm) Take-home tests Evenings (5:00pm – 8:00pm) We frequently recruit for focus groups that require a 2 hour time commitment during the normal business work day (8 am - 4 pm, Monday through Friday). *Would you be available for a 2 hour session on a weekday, generally between 10am and 4pm?   Yes No Do you have access to the internet in a location where you would be able to participate in online tests?   Yes No Do you have high speed internet access?   Yes No N/A What type of computer would you use to access the internet?   PC MAC N/A The following sections must be completed thoroughly, accurately and in its entirety, as the information will be used to select panelist for individual studies. *Total number of people living in your household: *Number of ADULTS in your household: (include children 19 years old or older)  *Number of CHILDREN in your household: (18 years old or younger)    Child's Name: Gender: Birthdate: mm/dd/yyyy 1) M F 2) M F 3) M F 4) M F 5) M F If you have children that would like to participate, you can fill out an online Child's Survey or contact us at 402-240-3140 to learn more. *What is your ethnic background?   African American Asian Hispanic/Latino Native American Caucasian Other *What is the highest level of education you have completed?   Grade School High School Trade/Technical School Associates Degree Bachelors Degree Advanced College Degree i.e., Masters, Doctoral *Do you work outside the home?   Yes No *What is your employment status?   Unemployed Part-time Full-time Retired *We sometimes conduct research that requires us to recruit people from specific industries and types of employment. Do you, or anyone in your household currently work in any of the following? (Check all that apply) Medical Field, (e.g., nurse, physician, dental hygienist, laboratory technician) Media (e.g., newspaper journalist, reporter, magazine editor) Health and Beauty (e.g., hair stylist, masseuse, yoga/pilates instructor, personal trainer, dietician) Computer and IT Systems (programmer, computer repair, computer sales, tech support) Transportation (e.g., auto sales, service or repair, bus/cab driver, pilot) Marketing (e.g., advertising, consumer research, market research) Education (e.g., teacher, school administrator) Grocery and Food (manager, food product developer, chef) Other: None of the above *Are you or anyone in your household currently/or have been employed within the last 12 months by any of the following companies? (Check all that apply) Blue Bunny Kellogg's General Mills ConAgra Nestle Unilever Hershey Frito Lay Coca-Cola Quaker Pepsi Co. Tyson Campbell's Kraft Other Food Manufacturers None of the above *Annual Household Income: less than $20,000 between $20,000 and $29,999 between $30,000 and $39,999 between $40,000 and $49,999 between $50,000 and $59,999 between $60,000 and $69,999 between $70,000 and $79,999 between $80,000 and $89,999 between $90,000 and $99,999 more than $100,000