Work, Education & Other Info
Employment Status
Please Select
Full Time
Part Time
Unemployed
Homemaker
Student
Disabled
Retired
Title
Company
Education Completed
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Less than High School
High School
Some College
College Graduate
Post Graduate
Race/Ethnicity*
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White or Caucasian
Black or African American
Hispanic or Latino
Asian or Pacific Islander
Multiracial
Other
Party Affiliation
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Democrat
Republican
Independent
Other
Unknown/Refused
Household Info
Marital Status
Please Select
Married
Living with Significant Other
Divorced/Separated
Single
Widowed
Annual Household Income
Please Select
Under $15,000
$15,000 to $19,999
$20,000 to $29,999
$30,000 to $39,999
$40,000 to $49,999
$50,000 to $59,999
$60,000 to $74,999
$75,000 to $99,999
$100,000 to $124,999
$125,000 to $149,999
$150,000 to $174,999
$175,000 to $199,999
$200,000 to $249,999
$250,000 and over
What is your housing type?
Please Select
Single Family Home
Apartment
Condominium or Town Home
Dormitory or Student Housing
If you have children under age 18, please provide their dates of birth and genders below. If you have children over age 18, please ask them to register with us.
Child 1
Birthdate
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
Year
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
Gender
Please Select
Female
Male
Child 2
Birthdate
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
Year
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
Gender
Please Select
Female
Male
Child 3
Birthdate
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
Year
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
Gender
Please Select
Female
Male
Child 4
Birthdate
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
Year
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
Gender
Please Select
Female
Male
Child 5
Birthdate
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
Year
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
Gender
Please Select
Female
Male
Child 6
Birthdate
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
Year
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
Gender
Please Select
Female
Male
Tobacco & Related Info
Do you smoke cigarettes?
Yes
No
If so, cigarette brand you smoke most often :
Please Select
305’s
Basic
Benson & Hedges
Cambridge
Camel
Capri
Carlton
Chesterfield
Doral
Eve
GPC
Kamel
Kent
Kool
LM
Lark
Liggett
Lucky Strike
Malibu
Marlboro
Maverick
Merit
Misty
Monarch
Montclair
More
Natural American Spirit
Newport
Now
Old Gold
Pall Mall
Parliament
Pyramid
Salem
Saratoga
Sonoma
Tareyton
True
USA Gold
Vantage
Viceroy
Virginia Slims
Winston
Generic or Private Label
Other Brand
Flavor of cigarette you smoke most often :
Please Select
Menthol
Non-Menthol
Size of cigarette you smoke most often :
Please Select
85s (Regular)
100s
120s
72s
Other Size
Color you request when purchasing your most often cigarettes:
Please Select
Black
Blue
Gold
Green
Orange
Pink
Purple
Red
Silver
Yellow
Other Color
Do you use e-Cigs or electronic cigarettes?:
Please Select
Yes, currently
Yes, sometimes
No, but I have tried or used to use them
No, I have not tried them
If you use moist snuff tobacco or dip, which brand do you use most often :
Please Select
Cooper
Copenhagen
Cougar
Gold River
Grizzly
Husky
Kayak
Kodiak
Longhorn
Red Seal
Redwood
Renegades
Revel
Rooster
Silver Creek
Skoal
Timber Wolf
Other
Cut of moist snuff/dip you use most often :
Please Select
Fine Cut
Long Cut
Pouches
Other
Flavor of moist snuff/dip you use most often :
Please Select
Regular/Natural
Straight
Wintergreen
Apple
Berry
Cherry
Citrus
Grape
Ice
Mint
Peach
Spearmint
Vanilla
Other
Other Info
Would you consider participating in an interview in your home that may be audio and/or videotaped?
Yes
No
How were you referred to our website?
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Email from AOC Research
Facebook Ad
Facebook Post/Share from Friend
Flyer or Card
Friend or Family
Mall Advertisement
Show/Event/Festival
Other
If you were referred by someone, please tell us who: