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Country Select One Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Democratic Republic of Congo Denmark Disputed Territory Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Federated States of Micronesia Fiji Finland France French Guyana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and Mcdonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Iraq-Saudi Arabia Neutral Zone Ireland Israel Italy Ivory Coast Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Occupied Territories Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Helena and Dependencies Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and South Sandwich Islands South Korea Spain Spratly Islands Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks And Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United Nations Neutral Zone United States United States Minor Outlying Islands Uruguay US Virgin Islands Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Serbia Montenegro

GenderMale Female

Date Of BirthDate 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    Month Month January February March April May June July August September October November December    Year 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 1999 2000

Highest Level of Education Completed

 Less than High School

 High School Graduate

 Post High School Vocational or Technical School

 Some College

 Two Year College Graduate

 Four Year College Graduate

 Post Graduate Degree

Estimated Annual Household Income Before Taxes

 Below $25,000

  $25,000 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 $89,999

 $90,000 or Higher

Do you rent or own your home?Own  Rent

Do you have access to the Internet at home?Yes  No

Have you participated in any focus groups in the past?Yes  No

If yes, how many?

What were the topic(s)?

Date that you last participated in a focus group:

Type of Occupation

 White Collar/Administrative/Clerical

 Blue Collar/Service/Manufacturing

 Stay at Home/Do not work

 Unemployed

 Student

 Retired

Other, Specify:   

Your Occupation or Industry

Are you an employee of the local, state, or federal government?

 Yes, local government

 Yes, state government

 Yes, federal government

 No

Work SchedulePart Time Full Time