Consumer Taste Panel Screener

CONSUMER TASTE PANEL SCREENER

The IEH Laboratories & Consulting Group (IEH) is based in Lake Forest Park, WA. IEH conducts research and consulting activities in Sensory and Consumer Testing for agricultural producers and private food companies.

Sensory and consumer testing is critical for new product development and improving existing products. Most companies conduct consumer testing of their products to better understand consumer behavior and food choices, and to integrate consumer needs and wants in developing a new product.

We are conducting a general recruitment of people who may be interested in participating in future consumer taste tests. If you are interested, please complete this questionnaire for our database of potential test participants. If you are chosen to participate in any future consumer taste tests you will be paid for your time. Each test can take from 15 minutes to an hour depending on the product(s) being tested.

If you would like to be in our database, please fill out this questionnaire truthfully and to the best of your ability. Your participation is voluntary and you may refuse to answer any question(s) for any reason. People in the same household are eligible and welcome to complete a separate questionnaire. You must be 18 years or older to complete the questionnaire. All information you provide is voluntary, strictly confidentia l and will be for internal use only by the Sensory and Consumer staff. All consumers in the database are given a unique identification code that is used for data reporting to clients; names and personal contact information is never given out.

Your information and opinion are highly valued. If you have questions or concerns, please contact us at [email protected]

Thank you for your interest and response.

IEH Laboratories & Consulting Group Corporate office 15300 Bothell Way NE Lake Forest Park, WA 98155 206-522-5432 (Office) 206-306-8883 (Fax) E-mail: [email protected]

CONSUMER TASTE PANEL SCREENER

This contact information will not be shared with any other party. It will only be used to contact you with information regarding upcoming taste tests. Please note that e-mail is our primary method of contact.

Name: Last, First Middle

Address: Street

City State Zipcode Phone: ( )- - Email:

Preferred method of contact: E-mail Phone

PLEASE ANSWER THE FOLLOWING QUESTIONS

1. Do you have any of the following?

Yes No

Dentures

Diabetes

Oral Disease

Hypoglycemia

Food Allergies

Hypertension

If Yes, Please specify

2. Do you suffer from an impaired sense of smell or taste, or have you ever been diagnosed by a doctor that your normal ability to smell and taste has been affected, as a result of:  Trauma/ injury to the head or neck area  Head/ nose/ ear surgery  Illness (such as ear infection, flu) No Yes

3. Have you been diagnosed with color blindness or a vision impairment that remains even after use of corrective lenses? No Yes

4. Are you currently taking any medications that may affect your eating habits, or your ability to taste and smell? No Yes, Please explain ______

5. Do you have any dietary restrictions or foods you cannot eat? (Including food allergies or food intolerances) No Yes, Please specify ______

6. Do you smoke or use tobacco products? No On occasion (e.g., social smoker) Yes

DEMOGRAPHICS QUESTIONS: On occasion, we conduct cross-cultural studies to better understand food preferences and opinions between different ethnic/racial, age and gender groups. We also conduct tests with people representative of the widest cross section of the population. For this reason we have included ethnicity, identity and demographic questions. Your answers to this questionnaire are important to assist us in recruiting you for those tests you are best qualified for and interested in participating

7. What is your gender? Female Male

8. Please give your date of birth: (month/day/year) NOTE: Must be 18 years or older to complete the questionnaire.

9. Which of the following best describes your racial/ ethnic identity? (Please check all that apply). African American American Indian Asian or Pacific Islander Hispanic or Latino American White or Caucasian Multi-Ethnic Other ethnic background Decline to respond

10. What was the last grade of school you completed? (Choose One Answer) Some high school or less Completed high school Some college Completed college Graduate school Other education beyond high school Decline to respond

11. How would you describe your current employment status? (Choose One Answer) Full-time Part-time Self-employed Unemployed Retired Homemaker Student Decline to respond

12. What is your household’s total annual income, before taxes, from all sources? (Choose One Answer) Less than $10,000 $10,000 - $19,000 $20,000 - $29,000 $30,000 - $39,000 $40,000 - $49,000 $50,000 - $59,000 $60,000 - $69,000 $70,000 - $79,000 $80,000 - $89,000 $90,000 - $99,000 $100,000 or more Decline to respond

Thank you for your participation!

Each test is different and you may be notified as the need for your opinion arises. Participants will also be required to fill out an additional form regarding product usage before each test. You will be notified of future tests through e-mail or phone

If you experience any problems with this form or web site, please email [email protected]