Radio Listeners Brain Imaging Study

First Name

Last Name

E-mail Address

Age

Date of Birth

Gender

Ethnic Origin

Occupation of Head Of Household

Your Occupation

Address

Post Code

Contact Number

Are you a permanent resident in the UK and been living in the UK for the last year?

Yes, I am a permanent UK resident and have lived in the UK for the last yearNo, I am not a permanent UK residentI am a UK resident but I have not lived in the UK for at least one year

Have you taken part in a Brain Imaging Study in the past?

YesNoNot sure

Have you been contacted by another Market Research Recruiter to take part in this or any other Brain Imaging Study recently?

YesNoNot sure

Do you suffer from...

EpilepsyMigrainesNeither

How often do you suffer from migraines?

Once or twice a weekOnce a monthLess than once a monthNever

What triggers your migraines?

Do you suffer from severe sensitivity to light?

YesNo

Have you had any Brain Surgery or had any type of Brain Injury in the past?

YesNo

This study requires access to your scalp - do you wear a wig, hairpiece or any other head coverings or anything that will make access to your scalp difficult?

YesNo

Do you or any members of your household currently work, or have worked in the last year, in any of the following industries/occupations?

Advertising agency or advertising department within a companyMedia/Journalism/PublishingMarket ResearchMarketingManagement ConsultingPublic RelationsRadioNone of the above

What is your working status?

Full timePart timeStudentNonRetired

Which of the following activities do you do, and how often?

Reading a print newspaper or magazine
Every day2 or 3 times a weekLess oftenNever

Watching commercial TV (TV that carries advertising)
Every day2 or 3 times a weekLess oftenNever

Listening to commercial radio (radio that carries advertising)
Every day2 or 3 times a weekLess oftenNever

Using social media
Every day2 or 3 times a weekLess oftenNever

Are there any of these radio stations that you would AVOID when looking for a station to listen to?

Radio 1Radio 2Radio 3Radio 4HeartCapitalSmoothKissMagicOpen to all

Are there any of the following tasks that you WOULD NEVER DO?

CookingDriving (as driver)Light houseworkGrocery shoppingChecking emailsGardeningCrosswords or puzzlesPainting & decoratingOpen to all

During the research study, you will be required to do a few minutes of light exercise on an exercise bike. Can you please confirm that there is no medical or other reason that would prevent you from doing this activity?

I confirm that there is no medical or other reason that would prevent me from doing a few minutes of light exercise on an exercise bike during the study

Are you happy with the information you’ve just given to be shared with Emerald Fieldwork and Neuro Insight? (Emerald Fieldwork are co-ordinating the whole recruitment process and Neuro Insight is the company who is carrying out the research)?

YES I AM HAPPY FOR THE INFORMATION TO BE SHAREDI AM NOT HAPPY FOR THE INFORMATION TO BE SHARED

Which group are you interested in attending?

GROUP 1: Monday 11th February - 2.00pmGROUP 10: Tuesday 12th February - 3.30pmGROUP 12: Tuesday 12th February - 6.30pmGROUP 16: Wednesday 13th February - 12.30pm