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Background Questionnaire
All Answers Are Kept Confidential and Will Not Be Shared
with Other Focus Group Participants
Name
*
First Name
Last Name
Birthdate
MM
DD
YYYY
Place of Birth
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
How long have you lived at this address?
How did you hear about this focus group?
Occupation
If Retired or Unemployed, please also include your past occupations
Briefly describe your job duties
Employer
Type of Business
How Long Have You Been with this Employer?
Children Names, Sex, Ages, Occupation (if adults)
Political Party
Republican
Democrat
Libertarian
Other
No Political Party
Hobbies
Religion
How Do Get the News?
Please list the TV channels and internet sites you regularly watch/check for local and national news
Favorite TV Channels and Shows
Social Media
Select each site you regularly use
Facebook
Instagram
Twitter
LinkedIn
TikTok
Snapchat
Have you ever served on a jury?
Yes
No
If you answered yes, was the case a criminal or civil case?
Criminal
Civil
If you answered yes, please briefly describe the case
Have you ever been a plaintiff or a defendant in a lawsuit?
Yes
No
Have you or a family member suffered a serious injury?
Yes
No
Do you or a family member suffer from a long-lasting medical condition?
Yes
No
If you answered yes to any of the three preceding questions, please describe:
In return for financial consideration, I agree to keep the information I learn confidential and will not disclose the facts of this case to anyone. I agree to being recorded and videotaped.
*
Typing your name constitutes your signature
Thank you! Please return to the Focus Group and type “Done” in the chat box.
