SOHO Research Centre at MCG

Participate in a Focus Group

So we can match you to our studies, please fill out this form as completely as possible. We respect your privacy. Information that you provide in this form is kept strictly confidential.

First Name:

Last Name:

Address:

State:

Zip:

Work Telephone:

Home Telephone:

Cell phone:

Email Address:

Gender:

Female
Male

What is your employment status?

What is your Job Title?
(if Physician, please note type)

What is your age?

Racial or ethnic background

Other:

Marital Status

Highest Level of Education Completed

Estimated Annual Household
Income Before Taxes

Do you rent or own your home or apartment?

Rent
Own

Do you have access to the Internet at home?

Yes
No

Do you have children?

Yes
No

If yes, ages:

Do you own a car?

Yes
No

What are some of your hobbies and interests?

Have you participated
in any focus groups in the past?

Yes
No

If yes, how many?

What were the topic(s)?

Participate in a Focus Group So we can match you to our studies, please fill out this form as completely as possible. We respect your privacy. Information that you provide in this form is kept strictly confidential.
First Name:		Last Name:
Address:
State:		Zip:
Work Telephone:
Home Telephone:
Cell phone:
Email Address:
Gender:	Female Male
What is your employment status?
What is your Job Title? (if Physician, please note type)
What is your age?
Racial or ethnic background	Other:
Marital Status
Highest Level of Education Completed
Estimated Annual Household Income Before Taxes
Do you rent or own your home or apartment?	Rent Own

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

Do you have children?	Yes No	If yes, ages:

Do you own a car?	Yes No

What are some of your hobbies and interests?
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: