11/14/02 #75207068 ID# 

WEIGHT LOSS STUDY (0 1 -05) 

SCREENING QUESTIONNAIRE 

1 Arlington 

2 Austin 

3 Boston 

4 St. Charles 

5 Colorado Springs 

6 Edison 

(08) (09) 

Quota Groups 

AGE GENDER 

7 Los Angeles 1 18-29 1 MAE 

8 Poughkeepsie 2 30-44 2 FEMALE 

9 Schenectady 3 45-59 

10 Seminole 4 60 and over 

11 Toledo 

12 Wichita 

Recruiter's Name: START: 

Interviewer's Name: STOP: 

' Editor's Name: LENGTH: 

I CHECK QUOTAS 

I SIGHT SCREEN FOR MALES AND FEMALES 18 YEARS OF AGE OR OLDER. 

Hello, I'm from U,S.Researcb, a nationwide market research company. I assure you 

that we are not selling anphing ... all we want are yous honest opinions. Could you spare us a few 

minutes to answer some brief questions? 

A. In the past 12 months, have you tried to lose weight or gone on a diet? 

1 YES (CONTINUE) (10) 

2 NO (TERMINATE AND TALLU) 1 2 3 4 5 6 7 8 9 10 (1 1-12) 

B. Which of the following, if any, have you used to help you lose weight in the last 12 

months? 

1 A weight loss product such as Slim Fast? 1 YES 2 NO (13) 

2 A weight loss program such as Weight Watchers 

or Jenny Craig? I YES 2 NO (14) 

3 A diet plan such as the Atkins diet? 1 YES 2 NO (1 5) 

4 A prescription medication for weight loss? 1 YES 2 NO (16) 

5 A dietary supplement or herbal product for weight loss? 1 YES 2 NO (1 7) 

IF "YES" TO ANY OF THE ABOVE, CONTINUE. IF ""NO" TO ALL OF THE 

ABOVE, TERNIINATE AND TALLY 1 2 3 4 5 6 7 8 9 10 (18 
C. Do you or does anyone in yom "nusehold work ... 

In mxketing research? 

In advertising or public relations? 

For a store or company that markets a weight loss product, medication, or program? 

For a store in this shopping mall? 

IF YES TO OF THE ABOVE, 

TERMINATE ANDTALLY 1234567 8 9 10 (20-2 1) 

D. During the past six months, have you participated in any market research survey other 

than a political poll? 

1 YES (TERMINATE AND TALLM 1 2 3 4 5 6 7 8 9 10 (22-23) 

2 NO (CONTINUE) (24) 

E. Which of these goups includes your age? (NAD LIST) 

1 Under 18 (TERIMINATE AND TALLY) 1 2 3 4 5 6 7 8 9 10 (25-26) 

2 18-29 CHECK QUOTAS (27) 

3 30-44 CHECK QUOTAS 

4 45-59 CHECK QUOTAS 

5 60 and over CHECK QUOTAS 

6 =FUSED (TERMINATE AND TALLY) 1 2 3 4 5 6 7 8 9 10 (28-29) 

OVER QUOTA (TERIMINATE AND TALLV 1 2 3 4 5 6 7 8 9 10 (30-3 1) 

F. Do you usually wear eyeglasses or contact lenses when you read? 

1 YES (CONTINUE) 

2 NO (ASK QH) 

6. Do you have yom eyeglasses or conhct lenses with you today? 

1 YES (CONTINUE) 

2 NO (TERIMINATE AND TALLU) 1 2 3 4 5 6 7 8 9 10 

H. I'd like you to accompany me to the interviewing area where I will show you some 

advertising materials and then ask you some questions about it. We'll be giving you 

$2.00 to thank you for participating. I think that you'll find it interesting, and it will take 

only a few minutes. 

Before we continue, 1 need to obtain your name and telephone number. You may be contacted later to 

verify that the interview occurred, but information you provide will be kept confidential and will not be 

used to sell you anything. 

[IF AGRIEEABLE, ESCORT TO INTERVIEWING FACILITY. IF QUALIFIED 

BUT REFUSED, TERR'LINATE AND TaLU) 1 2 3 4 5 6 7 8 9 10 (3 6-3 7) 

I. mCORD (DO NOT ASK) 

1 MALE CHECK QUOTAS 

2 FEMKE CHECK QUOTAS 
THIS PAGE WILL BE COMPLETED IN IN FACILITY BEFOm 

INTERVIEW IS CONDUCTED. - 

WSCREEN RESPONDENT). 

PRINT NAME OF RESPONDENT: 

RECORD TELEPHONE NUMBER INCLUDING AmA CODE, 

AND THAT THE PHONE RINGS. 

(If nuder dialed is a non-working number, terminate and tally by circling lSt 

availablenumber 1 2 3 4 5 6 7 8 9 10 (3 9-40) 

I certify that I dialed the number and that it is a working number. 

Name (PMNT): 

Signature: