Respondent Database Input Form
The data we collect is used for market research purposes only.

We do not sell or otherwise release any personal information, EVER!
By completing this form your information will be entered into our database. When your information matches current research study criteria we may call you to inquire about your potential participation.
Please complete the entire form.
NOTE: This form asks for information about you AND others in your household.
If you quality for a study and choose to participate
we will pay you for your time.
Fees paid are determined by the sponsors of each study.
(Fields marked with an asterisk "*"are required)
 

Consumer Opinion Services Inc.

Last name*

First name (plus nickname, if any)*

Home Phone*
(Please enter your house land-line number here even if you do not use the land line to receive calls)

Work Phone

 Ext.

Fax Number

Cellular Number

E-mail address

Home Address*

Home City*

Home State
(If in USA)

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

Home US zip
(Plus 4 if you know it)

County you reside in

Work Address

Work City

Work State
(If in USA)

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

Work US zip
(Plus 4 if you know it)

County you work in

Your Employer (company name)

Your Job Title or description

Your Date of Birth*

Month January February March April May June July August September October November December

  Day 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

Year 1898 1899 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 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

Your Gender

Male Female

Your Curent Marital Status

Divorced/Separated Married Partnered Single Widowed

Total Household Income from all sources

Under 15,000 15-19,999 20-29,999 30-39,999 40-49,999 50-59,999 60-69,999 70-79,999 80-89,999 90-99,999 100 - 125,000 125 - 150,000 150 - 200,000 200,000 or more

Please choose the option that best describes your Education

0-8th Grade Some High School High School Grad/GED Some College College Grad 4yr Advanced Degree College 2yr Degree Technical School

Please choose the option that best describes your Ethnicity
(You may add details to notes field)

Asian African American East Indian Hispanic American Indian Native Alaskan/Eskamo Multi-Racial/Other Pacific Islander/Samoan Caucasian
Notes:

Please choose the voter option that currently best applies

Democrat Republican Independent Not Registered Other

Housing Type choose that that best describes
(You may add details to notes field)

Own Home Own Condominium Mobile Home Rent House Apartment Live with Parents Dorm/Frat House Other
Notes:

Have you had children but they are all now grown and out of the house?

All grown and gone No

Children?

Never had children Have children

If your children are living with you please include their date of birth. If they are not living with you their name and gender is sufficient.

Name of the oldest child
(You may add details to notes field)

Notes:

Gender

Male Female

Birthday of oldest Child

Month January February March April May June July August September October November December   Day 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 Year 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 2003 2004 2005 2006 2007 2008

Name of the second child
(You may add details to notes field)

Notes:

Gender

Male Female

Birthday of second Child

Month January February March April May June July August September October November December   Day 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 Year 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 2003 2004 2005 2006 2007 2008

Name of the third child
(You may add details to notes field)

Notes:

Gender

Male Female

Birthday of third Child

Month January February March April May June July August September October November December   Day 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 Year 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 2003 2004 2005 2006 2007 2008

Name of the fourth child
(You may add details to notes field)

Notes:

Gender

Male Female

Birthday of fourth Child

Month January February March April May June July August September October November December   Day 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 Year 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 2003 2004 2005 2006 2007 2008

Name of the fifth child
(You may add details to notes field)

Notes:

Gender

Male Female

Birthday of fifth Child

Month January February March April May June July August September October November December   Day 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 Year 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 2003 2004 2005 2006 2007 2008

Name of the sixth child
(You may add details to notes field)

Notes:

Gender

Male Female

Birthday of sixth Child
(Additional Children can go in notes)

Month January February March April May June July August September October November December   Day 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 Year 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 2003 2004 2005 2006 2007 2008
Note additional children below:

Where do you live?

Inside Washington State In US but not in Washington State Outside the US

Do you use a computer at home?

Yes   No 

Do you have Internet Access on your home computer?

Yes   No 

Do you have Dial-up home internet conection?

Yes   No 

Do you have DSL home internet conection?

Yes   No 

Do you have Cable home internet conection?

Yes   No 

Do you have Wireless home internet conection?

Yes   No 

Do you use a Cellular Telephone?

Yes   No 

Do you Text Message?

Yes   No 

Do you Have A Camera Phone?

Yes   No 

Do you Have a Play Station, X-Box, or Game Cube?

Yes   No 

Do you have a Wii?

Yes   No 

Are you Registered to vote at this address?

Yes   No 

Do you Have a Pager?

Yes   No 

Do you Have an MP3 player or Ipod?

Yes   No 

Do you Have a PDA Digital Assistant?

Yes   No 

Do you Have Web TV?

Yes   No 

Are you a regular runner or jogger
(at least 3 times a week)?

Yes   No 

Do you have a pet Cat?

Yes   No 

Do you have a pet Dog?

Yes   No 

Are you a union member?

Yes   No 

What type of radio do you listen to regularly?
(Select up to 5. Hold down the <Ctrl> key while clicking to make multiple selections)

Big Band Blues Christian / Gospel Classical Country / Western Easy Listening News NPR Oldies PBS Pop Rock Soft Rock Sports Talk Top 40's Variety 60's Music 70's Music Folk Jazz Other Not Listed

Have you been diagnosed with Diabetes?
(Select all that apply. Hold down the <Ctrl> key while clicking to make multiple selections)

No Diabetes Diabetic Type 1 Type 2 Tests blood daily Uses Gluclose Strips Use Meter Use Pills/Oral Meds Use Insulin Use Insulin Pen Continuous Pump Diet & Exercise

Have you been diagnosed with Cardio Vascular disease?
(Select all that apply. Hold down the <Ctrl> key while clicking to make multiple selections)

No Cardio Vascular Concerns Heart Condition CHF - Chronic Heart Failure COPD-Chronic Obstructive Pulmonary Disorder Heart Attack Hereditary High Blood Pressure / Hypertension High Cholesterol / Hyperlipidemia Over Weight Diagnosed Stroke Uses Coumadin/Warphin

Do you have Allergies?
(Select all that apply. Hold down the <Ctrl> key while clicking to make multiple selections)

No Allergies Has Allergies Food Drug Allergies Venom / Bee Stings Animals / Dander / Dust Perfume / Soap Perennial Seasonal / Pollens / Grass Uses Epipen

Do you have a restricted Diet?
(Select all that apply. Hold down the <Ctrl> key while clicking to make multiple selections)

No Dietary Constraints Medically Restricted Special Diet Low Cholesterol Low Sodium Sugar Restricted No Fish No Poultry No Red Meat Vegan - No Meat or Dairy Vegetarian - No Meat Jenny Craig Weight Watchers