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, if any, of the following types of food do you eat on a consistent basis * Required

Chicken

Beef

Pork

Shellfish

Legumes

What specific foods do you eat on a consistent basis? * Required

Chicken wings (bone-in or boneless)

Chicken tenders or nuggets

Hand-held sandwiches (hamburgers, sliders, etc.)

BBQ (ribs, tri-tip, etc.)

Pizza,

Tacos or burritos

Do you intend or plan on visiting/ordering from any of the following restaurants in the next 3 months? * Required

A. Popeye’s

B. Buffalo Wild Wings

C. Dominoes

D. Pizza Hut

E. Wingstop

F. KFC

G. Raising Cane’s

H. Chick-fil-A

Can you make a 2 hour study during the day in Tampa on April 24th for $190 * 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

sr.tampa@yahoo.com

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