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®
Kotex®
Stayfree®
Store Brand


Brands of Tampons
OB®
Tampax®
Kotex®
Playtex®
Store Brand


Brands of Pantiliners
Always®
Kotex®
Carefree®
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®

Target®

Walgreens®

CVS/pharmacy®

Meijer®

Kroger®

Bigg's®

Sam's Club® - Business Membership

Sam's Club® - Consumer Membership

Costco® - Business Membership

Costco® - Consumer Membership

Dollar Stores (i.e. 99¢enter, Dollar Tree®, etc.)

Dollar General®

Family Dollar®

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

Convenience Stores

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

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

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

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

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

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

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

Dollar Stores (i.e. 99¢enter, Dollar Tree®, 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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