Pre-Notification Survey

Become A Member Of The Digital Reflection Panel

We just want to confirm that you are still interested in joining the Digital Reflection Panel, so that we can send you the equipment you'll need to participate.

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What is your date of birth?

Month	Day	Year

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Please take the following survey so we can verify your contact information in order to send you the equipment.

* Are you still interested in joining the Digital Reflection Panel?

Yes

No

* Even though you're no longer interested, your opinion is still important to us. Please tell us why you're not interested. Thank you!

No time

Don’t remember signing up for Digital Reflection Panel

Not enough incentives/rewards

Health/personal reasons

Part of another panel

Other: Please specify

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Please wait...

We're happy that you are still interested in being part of the Digital Reflection Panel. In order to ensure the delivery of your equipment, please review your mailing address and primary phone number below:

Street Address:

City:

State:

Zip Code:

Phone Number:

* Is your contact information correct?

Yes

No

* Choose the information that needs to be corrected. Please select all that apply.

Address

Phone Number

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Please update the information below:

Street Address:

City:

State:

Zip Code:

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Please update the information below:

Your current Primary Phone Number =

* Phone Number :

Please update the information below:

Street Address:

City:

State:

Zip Code:

Your current Primary Phone Number =

* Phone Number :

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* Is there a wireless network router (WiFi) for connecting to the internet in your home with at least one open port?

Yes

No

* Are you the responsible party for the wireless network router?

Yes

No

How many of the following devices that can connect to the internet are there in your home? Please include only devices that are currently in use.

* Windows-based computers

* Macintosh/Mac computer

* Mobile or cellular phones (include any that connect to your home network)

* Tablet devices (for example, iPad, Samsung Galaxy Tab, Kindle Fire, etc.)

* iPod Touch