Eating Habits

First name

Last name

Phone

Address

City

State

Zip Code

Birthday * required

Occupation

Household Income

Ethnic Background

Living situation

Do you have children in the household? if yes, what are their ages

When is the last time you participated in a focus group or individual interview?

what are the topics of the studies you participated in the last 6 months

Do you, yourself, or anyone in your household fall into any of the following categories * Required

Restricted Diet

Vegetarian, Vegan, Organic, or Low sodium

restricted diet for religious reasons

food allergies

currently pregnant or breast feeding

Aversion to specific foods, such as fried or pre-packaged foods

undergone a major surgery that would impact your perception of foods and beverages

None

Which bagel shop/ Restuarant have you visited in the last month if any at all? * Required

PopUp Bagel

Panera

Einstein Bros.

Jeff’s Bagel Run

New York Bagel Café

St. Pete Bagel Co.

Stew’s House of Bagels

Clearwater Bagels

Homesick Bagels

Frida’s Café & Bakery

None

Can you make a 2 hour study during the day in Clearwater on June 15th or 16th for $175 * Required

Yes

Thanks for applying for our research project! We'll get back to you if we can use you for the study!

Superior Recruiting LLC

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