Personal Information
*First Name
*Last Name
*Date of Birth
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Before 1925
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
*Gender
Male
Female
Email Address
*Home Phone #
Work Phone #
Cell Phone #
Demographic Information
Highest level of education completed:
0-8th Grade
Some High School
High School Grad./GED
Some College
College Grad.
Advanced Degree
Race
African American/Black
Caucasian
Hispanic/Latin
Native American
Asian
Filipino
BiRacial
Other
*Marital Status:
CoHab
Divorced
Married
Separated
Single
Widowed
Work Information
Employment Status?
Full Time
Homemaker
Unemployed
Part Time
Retired
Are you a business owner?
Yes
No
Company Name:
*What is your occupation?
Account Executive
Accountant/CPA
Administrative Assistant
Administrator
Assistant
Attorney
Bookkeeper
Broker
Business Analyst
Business Owner
Clerical
Construction
Consultant
Counselor
Customer Service
Day Care Provider
Director
Disabled
Engineer
Entertainer
Executive
Financial Analyst
Government
Graphic Artist
Hair Stylist
Homemaker
Human Resources Specialist
Information Technology Specialist
Insurance
Laborer
Management
Medical Field
Nurse
Office Manager
Police Officer
Project Manager
Real Estate
Receptionist
Retail
Retired
Salesperson
Secretary
Social Worker
Student
Teacher
Teacher-college
Teacher-elementary
Teacher's Aide
Unemployed
Waitress/waiter
Other (Specify)
Other-please specify:
In what industry do you work?
Advertising
Aerospace
Agriculture, Fishing & Forestry
Arts, Entertainment & Recreation
Automotive
Buildings-Grounds/Cleaning/Maintenance
Chemical
Communications
Computer
Construction
Education
Education-Admin
Education-Elem
Education-High School or greater
Financial and Insurance
Food and Beverage(not grocery)
Government
Grocery
Health Care and Social Services
Hotel
Legal
Leisure and Hospitality
Manufacturing
Market Research
Marketing
Media-Press
Military
Natural Resources & Mining
Non-Profit
Personal Care Services
Pet Services
Printing
Professional/Scientific/Technical Services
Protective Services-Police, Firer and EMT
Public Administration
Publishing
Real Estate, Sales, Rental and leasing
Religion
Retail, Wholesale Trade
Sports
Training and Library
Transportation and warehousing
Travel
Utilities-telephone/power/water/disposal
Number of employees worldwide in your company:
Under 5 Employees
5-10 Employees
11-25 Employees
26-50 Employees
51-100 Employees
101-500 Employees
501-1000 Employees
Over 1000 Employees
Unknown
Business trips a year:
ZERO
1-5
6-10
11-19
20-29
30-39
40-49
50-59
60-69
70-79
80-89
90-99
100 or more
Spouse's occupation:
Account Executive
Accountant/CPA
Administrative Assistant
Administrator
Assistant
Attorney
Bookkeeper
Broker
Business Analyst
Business Owner
Clerical
Construction
Consultant
Counselor
Customer Service
Day Care Provider
Director
Disabled
Engineer
Entertainer
Executive
Financial Analyst
Government
Graphic Artist
Hair Stylist
Homemaker
Human Resources Specialist
Information Technology Specialist
Insurance
Laborer
Management
Medical Field
Nurse
Office Manager
Police Officer
Project Manager
Real Estate
Receptionist
Retail
Retired
Salesperson
Secretary
Social Worker
Student
Teacher
Teacher-college
Teacher-elementary
Teacher's Aide
Unemployed
Waitress/waiter
Other (Specify)
If you are a student, what school do you attend?
Household Information
*Home Address
*City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District 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
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
*Zip Code
County
Cook
Suburban Cook
Kane
DuPage
Will
Kankakee
McLean
McHenry
Lake
Kendall
Grundy
Other
*Are you the Head of the Household?
Yes
No
What type of home is this?
Own Condo/Townhouse
Own 3 Flat/Duplex
Own House
Own Other
Lives With Parents
Rent Apartment
Rent Condo/Townhouse
Rent 3 Flat/Duplex
Rent House
Rent Other
Yearly family income:
under 15,000
15-24,999
25-34,999
35-44,999
45-54,999
55-64,999
65-74,999
75-84,999
85-94,999
95-104,999
105,000-114,999
115,000-124,999
125,000-134,999
135,000-144,999
145,000-149,999
150,000 + over
How many children do you have living in your home?
0
1
2
3
4
5
6
7
8
9 or more
Child 1
Birthdate
January
February
March
April
May
June
July
August
September
October
November
December
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
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
Gender
Male
Female
Child 2
Birthdate
January
February
March
April
May
June
July
August
September
October
November
December
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
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
Gender
Male
Female
Child 3
Birthdate
January
February
March
April
May
June
July
August
September
October
November
December
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
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
Gender
Male
Female
Child 4
Birthdate
January
February
March
April
May
June
July
August
September
October
November
December
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
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
Gender
Male
Female
Lifestyle Products and Preferences
If you are pregnant, what is your due date?
January
February
March
April
May
June
July
August
September
October
November
December
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
What health conditions do you have?
(Select all that apply. Hold down the <Ctrl> key to make multiple selections)
Allergies
Arthritis
Asthma
Diabetes
Incontinence
Do you own a smart phone?
Yes
No
If so, what type of smart phone is it?
Do you own any of the following electronic devices?
(Select all that apply. Hold down the <Ctrl> key to make multiple selections)
Satellite TV
Smart Phone
Cable
iPad
Cell Phone
Laptop
Which of the following describes your access to healthcare?
Employer Provided
Marketplace
Medicare/Medicaid
Uninsured/No Insurance
Other
What is your primary method of watching television?
Cable
None
On-Line Streaming
Other
Satellite
What pets do you have?
(Select all that apply. Hold down the <Ctrl> key to make multiple selections)
Cat
Dog
Both
None
Other
What are your hobbies?
(Select all that apply. Hold down the <Ctrl> key to make multiple selections)
Amusement Parks
Arts & Crafts
Auto Racing
Biking
Blogging
Boating
Camping
Card Playing/Games
Computers
Cooking/Baking
Dancing
Decorating
Entertaining
Excerising
Fashion
Gambling
Gardening
Golf
Home Improvements
Movies
Music
Painting
Photo
Politics
Reading
Scrapbooking
Shopping
Singing
Skating
Social Networking
Socializing
Sports
Travel
TV
Video Games
Volunteering
Writing
Vehicle Information
Vehicle 1 and 2, Make, Model, Year
Vehicle 1
Make
* NO CAR
ACURA
ALFA-ROMEO
AM/AMC
ASTON MARTIN
AUDI
BENTLEY
BMW
BUICK
CADILLAC
CHEVROLET
CHRYSLER
COOPER
DAEWOO
DAIHATSU
DODGE
EAGLE
FERRARI
FIAT
FORD
GEO
GMC
HONDA
HUMMER
HYUNDAI
INFINITI
ISUZU
JAGUAR
JEEP
KIA
LAMBORGHINI
LAND ROVER
LEXUS
LINCOLN
LOTUS
MAZDA
MERCEDES-BENZ
MERCUR
MERCURY
MITSUBISHI
NISSAN
OLDSMOBILE
PEUGEOT
PLYMOUTH
PONTIAC
PORSCHE
RENAULT
ROLLS-ROYCE
SAAB
SATURN
SCION
SMART CAR
STERLING
SUBARU
SUZUKI
TOYOTA
TRIUMPH
VOLKSWAGON
VOLVO
YUGO
OTHER
Model
Year
Vehicle 2
Make
* NO CAR
ACURA
ALFA-ROMEO
AM/AMC
ASTON MARTIN
AUDI
BENTLEY
BMW
BUICK
CADILLAC
CHEVROLET
CHRYSLER
COOPER
DAEWOO
DAIHATSU
DODGE
EAGLE
FERRARI
FIAT
FORD
GEO
GMC
HONDA
HUMMER
HYUNDAI
INFINITI
ISUZU
JAGUAR
JEEP
KIA
LAMBORGHINI
LAND ROVER
LEXUS
LINCOLN
LOTUS
MAZDA
MERCEDES-BENZ
MERCUR
MERCURY
MITSUBISHI
NISSAN
OLDSMOBILE
PEUGEOT
PLYMOUTH
PONTIAC
PORSCHE
RENAULT
ROLLS-ROYCE
SAAB
SATURN
SCION
SMART CAR
STERLING
SUBARU
SUZUKI
TOYOTA
TRIUMPH
VOLKSWAGON
VOLVO
YUGO
OTHER
Model
Year
Participation in Studies
*What is your availability for studies?
Days
Evenings
Both
*Your location availability:
(Select all that apply. Hold down the <Ctrl> key to make multiple selections)
Downtown
Oak Park
Oak Brook
Bloomington/Normal, Illinois
Detroit
Atlanta
Other
Would you be interested in studies where we come to your home?
Yes
No
*How did you hear about us?
Call from Focuscope
Chicago Parent/Baby
Chicago Parents On-line
Facebook
Chicago Parent Going Places
Internet Search
KidWink
Oaklees
Paws Chicago/Angel Tales
Referral Program
Suburban Parents
The Bump
Update my file
Yelp.com
The Expectant Mother's Guide to Chicago
Knot.com
If you were referred by someone or heard about us from another source, please enter it here: