Database Questionnaire
Please fill the following information out with your
current address
& the way your
name appears on your picture ID
so that you can be added to our database. A representative of Focus & Testing will be calling you to verify the information you have provided and to ask you some additional questions. All of the information you have provided will be kept confidential and will be used for research purposes only. We will never try to sell you anything.
First Name
*
:
Last Name
*
:
Street
*
:
Apt. No.:
City
*
:
State
*
:
Zip
*
:
Phone
*
:
(home)
(work)
(other)
E-Mail
*
:
Gender:
Male
Female
Birth date
*
:
What is your ethnic background?
(Please pick one answer)
A)
African American
B)
White
C)
Asian,
Specify Heritage
D)
Latino,
Specify Heritage
Do you have any dietary restrictions?
A)
Yes, Specify:
B)
No
If we need to verify your ID for a study, do you have a driver's license or state ID?
A)
Yes. If yes, What is your license or ID number?
State:
No.:
B)
No.
Do you have a car?
A)
Yes:
Make:
Model:
Year:
Make:
Model:
Year:
Make:
Model:
Year:
B)
No.
What is your occupation?
What is your marital status?
A)
Single
B)
Married
C)
Separated
D)
Divorced
E)
Widowed
Do you have any children under the age of 18 living in your household?
A)
Yes
:
First Name:
Gender:
M
F
Birth date:
First Name:
Gender:
M
F
Birth date:
First Name:
Gender:
M
F
Birth date:
First Name:
Gender:
M
F
Birth date:
B)
No
What was your last grade of schooling?
A)
Less than High School
B)
High School
(# of years:
)
C)
College
(# of years:
)
D)
Post Graduate
(# of years:
)
E)
Vocational
(# of years:
)
Do you have a medical condition(s) that could be a topic of study?
A)
If yes, what is the condition:
B)
No
What is the average yearly income for your entire household before taxes?
$
WHO WE ARE
WHAT WE OFFER
THE FACILITY
TECHNOLOGY
REQUEST A QUOTE
DIRECTIONS/HOTEL
PARTICIPANTS
www.focusandtesting.com
info@focusandtesting.com
818.347.7077
5016 Parkway Calabasas, Suite 101
Calabasas, CA 91302
