1.  

 Please enter your name, address and telephone number:
   
               
Miss Ms. Mrs. Mr.        

First:

Last:

 

Street, RFD or Box No:

City:

 

State:

County:

 

Zip Code:

Telephone:

- -

(999 - 999 - 9999)

               
   

2.  

 Most of our surveys are conducted by mail. There are occasions when timing does not allow for mailing or we may need additional information and must contact our panelists or members of their households by phone. May I or my staff members phone you (or a member of your household) in these instances?
  Yes No  

3.  

 Your marital status:
Married Single Divorced Widowed Separated Domestic Partner
   

4.  

 Surveys often fail to represent all groups in a community. In order to be representative of the U.S. populations, we ask you to indicate your race below:
White Black/African American Asian Other (specify):
   

5a.  

 Are you or are other household members of Hispanic (Spanish) origin or background?
  Yes No (skip to Q.6)
   

5b.  

 To which Hispanic group do you or they belong?
Cuban Mexican Puerto Rican Other Spanish
   

5c.  

 How often is Spanish spoken in your home?
All or most of the time About 50% of the time Less than 50% of the time
   

6.  

 Now please list all members of your household living at home. List yourself on the first line. (Do NOT list persons who are away at college or in the armed forces; do NOT list persons in your home only on vacation.) Print each person’s first and last name, indicate the month and year born, their sex, and how they are related to you, if at all.
   
     

When Born?

Sex

Relationship to you

Person #

First Name

Last Name

Which
Month

Which
Year


Male


Female


Child


Parent

Other
Relative

Not
Related

1. Yourself:

 

 

 

 

2. Spouse:

 

 

 

 

3. Other.

4. Other.

5. Other.

6. Other.

7. Other.

8. Other.

 

 

 

 

 

 

 

 

7.  

 Looking at the “person numbers” in Q. 6 that identify your household members, which person (by number) do you consider to be the head of your family? This can only be yourself, a spouse, parent or other relative with whom you live.
  The head of the family is: person #
   

  

 If a male and female share the status of head of the family, please indicate which “person number” in Q. 6 is the:
 

Male head of the family: person #

Female head of the family: person #

   

8.  

 In this section please check the box that shows your highest level of education. If you have a spouse, please show that person’s highest level of education as well.
   
 
 

 

Business, Technical
Nursing School or

 

 

 

Grade School

High School

2 Year College

4 Year College

Received Degrees

Attended Graduated Attended

Graduated

Attended

Graduated

Attended

Graduated

Masters

Advanced Degree

Your Education

Spouse's Education

   

9.  

 Your employment status (check your primary category):
   
 

Full-time job - not at home

Full-time homemaker

Student - also work

Part-time job - not at home

Retired - no longer work

Student - do not work

Work from home

Temporarily unemployed

 

   
 

If you are employed:

 

a.What is your occupation?

 

b.What is your major responsibility?

 

c.What is your title or position?

 

d.What industry are you in?

 

   

10.  

 Please indicate below the income group that best describes your income if you are single, or the total income for all members of the household who are related to you. This means you would combine your income with a spouse, parents, brother, sisters and children who you may live with. Please include all wages, salaries, income from self-employment, rents, dividends, etc., before paying taxes. This information is important for statistical purposes and we guarantee that it is never revealed to anyone and we never sell or give your information to a mailing list.
   
 
Under $20,000 $35,000-$39,999 $70,000-$79,999 $120,000-$149,999
$20,000-$24,999 $40,000-$49,999 $80,000-$89,999 $150,000-$199,999
$25,000-$29,999 $50,000-$59,999 $90,000-$99,999 $200,000 and over
$30,000-$34,999 $60,000-$69,999 $100,000-$119,999  
   

11a.  

 Do you live in a
   
 
Single-Family house Multiple-family house or appartment Mobile home
Other type (specify)
   

11b.  

 Do you or your spouse (if any):
   
 
Own the house or appartment
     (with or without a mortgage)		 Pay rent to someone
 		 Have another situation
 
   

12.  
Do you have a dog? Yes No Do you have a cat? Yes No
   

13.  

 Does your household own a DVD Player? Yes No
   

14.  

 In which of the following ways does your household receive its television signal? (check all that apply)
   
 

A regular cable TV service
A satellite dish service
A digital cable TV service
Regular TV antenna
   

15.  

 Premium channels such as Home Box Office, Showtime, Cinemax, Encore, The Movie Channel and STARZ!, are channels for which you pay an additional fee. These channels provide current movies and special programs with no commercial interruptions. Does your household subscribe to any premium channels?
   
 
No      
Yes (check all that apply) HBO Showtime Cinemax
 

Encore          

 The Movie Channel STARZ! Other pay channels
   

16.  
Do you have one or more computers in your home? No (skip to Q18.) Yes
   

17.  

 Which one of the following types of services is the primary Internet connection for your household?
   
 
Dial-up modem Cable modem DSL Other
   

18.  

 While we conduct most of our surveys by mail, we are planning to make various surveys available online. Would you be interested in answering any of our surveys online?
   
 
Yes (Continue to Q.19) No
   

19.  

 We will never sell your e-mail address to anyone, or any other personal information, and we will never send you e-mail unrelated to our surveys. The primary purpose of our having your e-mail address is to update information or for our online surveys only. We promise to keep it completely confidential.
   
  Your e-mail address: