Personal Survey I

Pre-Screener

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* 1. Contact Info

Full Name

Address

City

State

ZIP Code

Age

Company (former)

Email Address

Phone Number

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* 2. In what country do you live?

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* 3. What is your LinkedIn?

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* 4. What is your date of birth (DOB)?

Date / Time

Date

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* 5. What is your gender?

Male

Female

Other

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* 6. Do you own a smartphone or PC that has access to the internet?

Yes

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* 7. What is your current occupation?

Executive/Board member

Employee

Civil servant

Dispatch / Contact service employee

Expert (doctor, lawyer, accountant, etc.)

Self-employed

Freelancer

Part-time employee

Student

Full-time housemaker

Unemployed

Retired

Other (please specify)

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* 8. What was a former occupation of yours?

Industry

Occupation

Job Description

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* 9. Do you or your relatives work in the following industries?

Manufacturing (soap, detergent, toiletries)

Manufacturing (pharmaceuticals)

Manufacturing (food)

Manufacturing (electricity and computer)

Manufacturing (others)

Wholesale and retail (soap, detergent, toiletries)

Wholesale and retail (pharmaceuticals)

Wholesale and retail (food)

Wholesale and retail (electricity and computer)

Wholesale and retail (department stores, supermarkets, convenience stores)

Wholesale and retail (others)

Transportation and Logistics

Telecommunications and information processing services

Travel agencies and travel

Hotel business and hospitality

Gastronomy (i.e. restaurants)

Real Estate

Finance

Electricity, Gas and Water

Publishing and printing

Media

Research, Advertising, Marketing

Other (please specify)

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* 10. What is your marital status?

Unmarried / Single

Married

Separated

Divorced

Widowed

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* 11. What is your living situation?

Live alone

Live with a life partner

Live with family member(s)

Live in a nursing home / care center