FocusJr

Name

Telephone number

Address

City

State

Zip code

Email address

What is your job title or position?

Are you:

Male
Female

What is your exact age?

Do you currently have any children living with you in your household?

Yes
No

Please list the ages of your children?

What is the total number of people living in your household?

Are you or is any member of your household employed by, laid off or unemployed from, or retired from any of the following types of companies?

An advertising agency
A public relations company
In the news media such as TV, radio, or newspaper
As the manager of a grocery store, supermarket, convenience store, discount store, drug store, or mass merchandiser like Walmart or Target
A market research firm or the market research department within a company
A company that manufactures, distributes or sells cosmetics
A company that manufactures, distributes or sells food and beverage products

In the past 6 months, have you participated in or are you scheduled to participate in any other marketing research projects including, but not limited to focus groups, interviews, surveys, etc.?

Yes
No

In the past 12 months, have you participated in any research studies listed below. If yes, then please check only those that you particpated in. If none then choose "none".

Oral Care
Weight Management
Food and Beverages
Pain Relief

Which of the following types of beverages have you consumed in the past 4 weeks?

Water
Sparkling Water
Milk
Juice (fruit or vegetable)
Fruit Drink
Zero Calorie Sodas
Regular Sodas
Tea
Coffee
Alcoholic Beverage
Other

Which, if any, of the following beverages would you NEVER consider drinking?

Water
Sparkling Water
Milk
Juice (fruit or vegetable)
Fruit Drink
Zero Calorie Sodas
Regular Sodas
Tea
Coffee
Alcoholic Beverage
Other

For each brand below, please estimate how often you drink (if at all) it on a monthly basis?

Dr. Pepper

Coke Life

Mr. Pibb

0
1
2 or more

Coke

0
1
2 or more

Pepsi

0
1
2 or more

Sprite

0
1
2 or more

Coke Zero/Coke Zero Sugar

0
1
2 or more

7-Up

0
1
2 or more

Diet Coke

0
1
2 or more

Fanta

0
1
2 or more

Which of the following ethnic groups to you identify with most strongly?

Caucasian
African-American
Hispanic/Latino
Asian/Pacific Islande
Native American
Bi-racial
Other

What is the highest level of education you have completed?

Less than high school
High School
Some College or Technical School
Bachelors Degree
Masters Degree +
Ph.D

Which of the following best describes your school/working situation, are you…?

Full-Time Student
Employed Full-Time
Employed Part-Time
Work From the Home
Stay-at-Home Parent
Unemployed

Which of the following best describes your total annual household income before taxes?

Under $20,000
$20,000 – $30,000
$30,000 – $40,000
$40,000 – $50,000
$50,000 – $65,000
$65,000 - $80,000
$80,000 - $100,000
$100,000 or more

Next, I will read you a series of statements. We’ll use a scale from 1-10 where “10” means the statements “describes your feelings extremely well,” and “1” means the statement “does not describe your feelings at all.”

If asked to describe something, I can usually do so in detail

1
2
3
4
5
6
7
8
9
10

I get excited about trying something I haven’t done before.

1
2
3
4
5
6
7
8
9
10

My friends consider me friendly and outgoing.

1
2
3
4
5
6
7
8
9
10

I look at and even enjoy some advertising

1
2
3
4
5
6
7
8
9
10

I like to use my imagination to come up with new ideas.

I am open about expressing my thoughts and feelings.

1
2
3
4
5
6
7
8
9
10

I enjoy meeting and talking to new people.

I see myself as creative.

1
2
3
4
5
6
7
8
9
10

I like to try new products.

For my last question, I’d like for you to use your imagination. There are no wrong answers to this question! If your life became a color, what color would it be and why?

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