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first name *
 		last name *
date of birth(mm/dd/yyyy) *
 		country born in *
gender *
 		marital status *
 education *
 income
home address *
 		city *
 		state *
zip *
 		county *
primary phone number *
area code
alternate phone number
area code
occupation *
 industry work in *
 employment *
email address *
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how did you hear about us? *
 political affiliation *
available for groups *
days
evenings
both


if single..
do you live with your parents?
yes
no

do you own a computer? *
yes
no

ethnicity *
white
black
asian
hispanic
other; please specify:  

do you have a? *
dog
cat
cellular phone
video game system
cable tv
satellite tv
none
 use the internet?*
yes
no

residence *
own
rent

do you smoke? *
no
yes
brand
Have you been diagnosed with, or suffer from:
Asthma
Heart Disease
High Blood Pressure 		Chronic Obstructive Pulmonary Disease
Chronic Bronchitis
Cancer, specify type:

 Diabetes
Emphysema
other, please specify:

Include the names of your children if they would like to participate in surveys

birth date
(mm/dd/yyyy)

name
of child
 
automobiles
year
   make
   model

If married, please fill in spouses information
If they would also like to participate in surverys

first name:
 last name:
date of birth
 gender
 education
 country born in
occupation
 industry work in
 		employment
email address
 area code
 primary phone
ethnicity
white
black
asian
hispanic
other, please specify:
 available for groups
days
evenings
both

does he/she smoke?
no
yes
brand
 

 phone type
Has he/she been diagnosed with, or suffer from:
Asthma
Heart Disease
High Blood Pressure 		Chronic Obstructive Pulmonary Disease
Chronic Bronchitis
Cancer, specify type: 		Diabetes
Emphysema
other, please specify:
I understand that once I qualify and am scheduled to participate in a survey, when I come to the facility I must bring a State Issued ID Card. *

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ClearView Research Chicago

8725 W. Higgins Road #150
Chicago, IL 60631
847-827-9840

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