Recruitment Survey - New copy IMP

Questions marked with an * are required

Welcome! Here’s the next step in continuing your application to join Digital Reflection Panel.

Please fill out the following questions completely and accurately. Do not click your browser's back button as you may lose information that you've entered.

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

Yes

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

Yes

* Are there children in the household?

Yes

* Are you the parent or guardian of all children in the household?

Yes

* Do you or any members of your household work for or participate in a market research company?

Yes

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

Prior Response Not Loaded - Please Insert a Page-Break Before the Custom Logic Script

Please wait...

* How many televisions do you have in your household?

* What type of TV service does your household use? Select all that apply.

TV digital tuner/TV antenna for local channels

Cable/Fiber TV service subscription

Satellite TV service subscription

Streaming or on-demand services using an internet connection

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* Who is your household’s current cable /satellite TV service provider?

* Who is your current home Internet Service Provider (ISP)?

If you become a panel member, we may need to contact you for periodic updates. A contact number is very important. This number will not be used for any other purposes other than by Digital Reflection Panel to contact you regarding membership.

* Primary phone type

Format 123-456-7890

* Phone Number: :

Alternative phone type

Number

Alternative phone type

Number:

Do you agree to allow Digital Reflection to call you for membership related questions?

Yes

* How many people, including yourself and any children, regularly live in your household? Please EXCLUDE any family members living away at school during the school year.

* For classification purposes only, what is your household’s annual income before taxes?

Please complete the following information about each member within your household, which includes yourself.

* Household member first name?

* What is this person’s gender?

Male

Female

* Is this person the head of the household?

Yes

* Does this person routinely use an internet connected device at home?

Yes

* What is the last grade of school this person completed?

8^th grade or less (including members too young for school)

Some high school

High school degree

Some college, but no college degree

College graduate

Graduate degree such as Master’s Degree, Ph.D, M.D., or L.L.D.

A degree from a post-secondary technical or vocational school

Associate’s degree

* What is this person’s current employment status?

Employed or self-employed full-time (30+ hours)

Employed or self-employed part-time (<30 hours)

Homemaker

Retired

Not employed

* What is this person’s race? (Select all that apply)

White

Black / African American

American Indian / Native Alaskan

Asian / Pacific Islander

Other

* Is this person of Spanish, Hispanic, or Latino origin?

Yes

* Which language does this person prefer to speak most often?

* What language does this person use most frequently when reading news, watching videos, or keeping up with friends?

Spanish all or almost all of the time

Mostly Spanish with some English

Both Spanish and English equally

Mostly English with some Spanish

English all or almost all of the time

Some other language

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Household member first name?

* What is this person’s birthdate?

Month	Day	Year

* What is this person’s gender?

Male

Female

* Is this person the head of the household?

Yes

* Does this person routinely use an internet connected device at home?

Yes

* What is the last grade of school this person completed?

8^th grade or less (including members too young for school)

Some high school

High school degree

Some college, but no college degree

College graduate

Graduate degree such as Master’s Degree, Ph.D, M.D., or L.L.D.

A degree from a post-secondary technical or vocational school

Associate’s degree

* What is this person’s current employment status?

Employed or self-employed full-time (30+ hours)

Employed or self-employed part-time (<30 hours)

Homemaker

Retired

Not employed

* What is this person’s race? (Select all that apply)

White

Black / African American

American Indian / Native Alaskan

Asian / Pacific Islander

Other

* Is this person of Spanish, Hispanic, or Latino origin?

Yes

* Which language does this person prefer to speak most often?

* What language does this person use most frequently when reading news, watching videos, or keeping up with friends?

Spanish all or almost all of the time

Mostly Spanish with some English

Both Spanish and English equally

Mostly English with some Spanish

English all or almost all of the time

Some other language

* Household member first name?

* What is this person’s birthdate?

Month	Day	Year

* What is this person’s gender?

Male

Female

* Is this person the head of the household?

Yes

* Does this person routinely use an internet connected device at home?

Yes

* What is the last grade of school this person completed?

8^th grade or less (including members too young for school)

Some high school

High school degree

Some college, but no college degree

College graduate

Graduate degree such as Master’s Degree, Ph.D, M.D., or L.L.D.

A degree from a post-secondary technical or vocational school

Associate’s degree

* What is this person’s current employment status?

Employed or self-employed full-time (30+ hours)

Employed or self-employed part-time (<30 hours)

Homemaker

Retired

Not employed

* What is this person’s race? (Select all that apply)

White

Black / African American

American Indian / Native Alaskan

Asian / Pacific Islander

Other

* Is this person of Spanish, Hispanic, or Latino origin?

Yes

* Which language does this person prefer to speak most often?

* What language does this person use most frequently when reading news, watching videos, or keeping up with friends?

Spanish all or almost all of the time

Mostly Spanish with some English

Both Spanish and English equally

Mostly English with some Spanish

English all or almost all of the time

Some other language

* Household member first name?

* What is this person’s birthdate?

Month	Day	Year

* What is this person’s gender?

Male

Female

* Is this person the head of the household?

Yes

* Does this person routinely use an internet connected device at home?

Yes

* What is the last grade of school this person completed?

8^th grade or less (including members too young for school)

Some high school

High school degree

Some college, but no college degree

College graduate

Graduate degree such as Master’s Degree, Ph.D, M.D., or L.L.D.

A degree from a post-secondary technical or vocational school

Associate’s degree

* What is this person’s current employment status?

Employed or self-employed full-time (30+ hours)

Employed or self-employed part-time (<30 hours)

Homemaker

Retired

Not employed

* What is this person’s race? (Select all that apply)

White

Black / African American

American Indian / Native Alaskan

Asian / Pacific Islander

Other

* Is this person of Spanish, Hispanic, or Latino origin?

Yes

* Which language does this person prefer to speak most often?

* What language does this person use most frequently when reading news, watching videos, or keeping up with friends?

Spanish all or almost all of the time

Mostly Spanish with some English

Both Spanish and English equally

Mostly English with some Spanish

English all or almost all of the time

Some other language

* Household member first name?

* What is this person’s birthdate?

Month	Day	Year

* What is this person’s gender?

Male

Female

* Is this person the head of the household?

Yes

* Does this person routinely use an internet connected device at home?

Yes

* What is the last grade of school this person completed?

8^th grade or less (including members too young for school)

Some high school

High school degree

Some college, but no college degree

College graduate

Graduate degree such as Master’s Degree, Ph.D, M.D., or L.L.D.

A degree from a post-secondary technical or vocational school

Associate’s degree

* What is this person’s current employment status?

Employed or self-employed full-time (30+ hours)

Employed or self-employed part-time (<30 hours)

Homemaker

Retired

Not employed

* What is this person’s race? (Select all that apply)

White

Black / African American

American Indian / Native Alaskan

Asian / Pacific Islander

Other

* Is this person of Spanish, Hispanic, or Latino origin?

Yes

* Which language does this person prefer to speak most often?

* What language does this person use most frequently when reading news, watching videos, or keeping up with friends?

Spanish all or almost all of the time

Mostly Spanish with some English

Both Spanish and English equally

Mostly English with some Spanish

English all or almost all of the time

Some other language

* Household member first name?

* What is this person’s birthdate?

Month	Day	Year

* What is this person’s gender?

Male

Female

* Is this person the head of the household?

Yes

* Does this person routinely use an internet connected device at home?

Yes

* What is the last grade of school this person completed?

8^th grade or less (including members too young for school)

Some high school

High school degree

Some college, but no college degree

College graduate

Graduate degree such as Master’s Degree, Ph.D, M.D., or L.L.D.

A degree from a post-secondary technical or vocational school

Associate’s degree

* What is this person’s current employment status?

Employed or self-employed full-time (30+ hours)

Employed or self-employed part-time (<30 hours)

Homemaker

Retired

Not employed

* What is this person’s race? (Select all that apply)

White

Black / African American

American Indian / Native Alaskan

Asian / Pacific Islander

Other

* Is this person of Spanish, Hispanic, or Latino origin?

Yes

* Which language does this person prefer to speak most often?

* What language does this person use most frequently when reading news, watching videos, or keeping up with friends?

Spanish all or almost all of the time

Mostly Spanish with some English

Both Spanish and English equally

Mostly English with some Spanish

English all or almost all of the time

Some other language

* Household member first name?

* What is this person’s birthdate?

Month	Day	Year

* What is this person’s gender?

Male

Female

* Is this person the head of the household?

Yes

* Does this person routinely use an internet connected device at home?

Yes

* What is the last grade of school this person completed?

8^th grade or less (including members too young for school)

Some high school

High school degree

Some college, but no college degree

College graduate

Graduate degree such as Master’s Degree, Ph.D, M.D., or L.L.D.

A degree from a post-secondary technical or vocational school

Associate’s degree

* What is this person’s current employment status?

Employed or self-employed full-time (30+ hours)

Employed or self-employed part-time (<30 hours)

Homemaker

Retired

Not employed

* What is this person’s race? (Select all that apply)

White

Black / African American

American Indian / Native Alaskan

Asian / Pacific Islander

Other

* Is this person of Spanish, Hispanic, or Latino origin?

Yes

* Which language does this person prefer to speak most often?

* What language does this person use most frequently when reading news, watching videos, or keeping up with friends?

Spanish all or almost all of the time

Mostly Spanish with some English

Both Spanish and English equally

Mostly English with some Spanish

English all or almost all of the time

Some other language

* Household member first name?

* What is this person’s birthdate?

Month	Day	Year

* What is this person’s gender?

Male

Female

* Is this person the head of the household?

Yes

* Does this person routinely use an internet connected device at home?

Yes

* What is the last grade of school this person completed?

8^th grade or less (including members too young for school)

Some high school

High school degree

Some college, but no college degree

College graduate

Graduate degree such as Master’s Degree, Ph.D, M.D., or L.L.D.

A degree from a post-secondary technical or vocational school

Associate’s degree

* What is this person’s current employment status?

Employed or self-employed full-time (30+ hours)

Employed or self-employed part-time (<30 hours)

Homemaker

Retired

Not employed

* What is this person’s race? (Select all that apply)

White

Black / African American

American Indian / Native Alaskan

Asian / Pacific Islander

Other

* Is this person of Spanish, Hispanic, or Latino origin?

Yes

* Which language does this person prefer to speak most often?

* What language does this person use most frequently when reading news, watching videos, or keeping up with friends?

Spanish all or almost all of the time

Mostly Spanish with some English

Both Spanish and English equally

Mostly English with some Spanish

English all or almost all of the time

Some other language

* Household member first name?

* What is this person’s birthdate?

Month	Day	Year

* What is this person’s gender?

Male

Female

* Is this person the head of the household?

Yes

* Does this person routinely use an internet connected device at home?

Yes

* What is the last grade of school this person completed?

8^th grade or less (including members too young for school)

Some high school

High school degree

Some college, but no college degree

College graduate

Graduate degree such as Master’s Degree, Ph.D, M.D., or L.L.D.

A degree from a post-secondary technical or vocational school

Associate’s degree

* What is this person’s current employment status?

Employed or self-employed full-time (30+ hours)

Employed or self-employed part-time (<30 hours)

Homemaker

Retired

Not employed

* What is this person’s race? (Select all that apply)

White

Black / African American

American Indian / Native Alaskan

Asian / Pacific Islander

Other

* Is this person of Spanish, Hispanic, or Latino origin?

Yes

* Which language does this person prefer to speak most often?

* What language does this person use most frequently when reading news, watching videos, or keeping up with friends?

Spanish all or almost all of the time

Mostly Spanish with some English

Both Spanish and English equally

Mostly English with some Spanish

English all or almost all of the time

Some other language

* Household member first name?

* What is this person’s birthdate?

Month	Day	Year

* What is this person’s gender?

Male

Female

* Is this person the head of the household?

Yes

* Does this person routinely use an internet connected device at home?

Yes

* What is the last grade of school this person completed?

8^th grade or less (including members too young for school)

Some high school

High school degree

Some college, but no college degree

College graduate

Graduate degree such as Master’s Degree, Ph.D, M.D., or L.L.D.

A degree from a post-secondary technical or vocational school

Associate’s degree

* What is this person’s current employment status?

Employed or self-employed full-time (30+ hours)

Employed or self-employed part-time (<30 hours)

Homemaker

Retired

Not employed

* What is this person’s race? (Select all that apply)

White

Black / African American

American Indian / Native Alaskan

Asian / Pacific Islander

Other

* Is this person of Spanish, Hispanic, or Latino origin?

Yes

* Which language does this person prefer to speak most often?

* What language does this person use most frequently when reading news, watching videos, or keeping up with friends?

Spanish all or almost all of the time

Mostly Spanish with some English

Both Spanish and English equally

Mostly English with some Spanish

English all or almost all of the time

Some other language

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Previously, you told us there are mobile phone(s) in your household. Please tell us what type each one is.

* Phone 1

* Phone 2

* Phone 3

* Phone 4

* Phone 5

* Phone 6

* Phone 7

* Phone 8

* Phone 9

* Phone 10

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Who is the primary user of each phone?

Prior Response Not Loaded - Please Insert a Page-Break Before the Custom Logic Script

Previously, you told us there are tablet(s) in your household. Please tell us what type each one is.

* Tablet 1

* Tablet 2

* Tablet 3

* Tablet 4

* Tablet 5

* Tablet 6

* Tablet 7

* Tablet 8

* Tablet 9

* Tablet 10

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Who are the household member(s) that use the tablet(s)?

Prior Response Not Loaded - Please Insert a Page-Break Before the Custom Logic Script

You're almost done! Click continue to review our privacy policy and agree to the terms in order to complete your panelist application.

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