Name:

Address:

City:

State:

Zip Code:

Email Address:

1. What is your gender?
male
female

2. Which of the following ranges includes your age?
    (select one answer)
18-24
25-31
32-40
41 or older

3. Are you the primary shopper in your household?
Yes
No

4. How often do you shop for groceries per month?
    (select one answer)
5 times a month
4 times a month
3 times a month
twice a month
once a month
less often than once month

5. On average, how much money do you spend on groceries in
    total per month?
    (select one answer)
under $50
$50 to $100
$101 to $200
$201 to $300
$301 to $400
$401 to $500
$501 or more

6. Have you ever used "BRAND X"
    (select one answer)
Yes
No
Don't know

7. How would you rate this product?
    (select one answer)
Excellent
Very Good
Average
Poor

8. How many times in the past 3 months have you purchased "BRAND X"
    (select one answer)
1
2-3 Times
More than 3 times

9. Did you think "BRAND X" was reasonably priced?
Yes
No

10. Have you ever heard of "BRAND Y"?
Yes
No

11. Where did you hear about "BRAND Y"?
    (select one answer)
Television
Magazine/Print Ad
Internet
Other

12. Which product are you most likely to purchase?
    (select one answer)
BRAND X
BRAND Y
BRAND Z
BRAND XX
BRAND YY
Other (Please specify)

13. Have you ever purchased any of these products over the Internet?
    (select one answer)
Yes
No

14. Have you ever pulled coupons or special offers for any of these products?
    (select one answer)
Yes
No

15. Does the pharmacy/drugstore you visit most frequently offer a frequent shopper program?
    (select one answer)
Yes
No