Sample Screening Questionnaire

I’m contacting you with a short questionnaire to verify your eligibility for an upcoming customer interview. This interview is an opportunity to provide feedback on something my startup is currently working on. This interview will help us better understand your needs in order to incorporate them into our product.

We’re currently scheduling participants for interviews that takes place Nov 29. Interviews will be held over a Google Hangout. If you’re interested in participating, please complete the questionnaire below. If you're selected, we’ll then be in touch directly to discuss details and set your appointment time.

Details of the study:
- The duration of the interview is 45 minutes
- You’ll receive $50 as a token of our appreciation *

To participate you will need to:
- Be at least 18 years old
- Sign a Non-Disclosure Agreement
- Allow us to video or audio record the session

* Please note that you won’t be compensated for responding to this questionnaire; you’ll receive a gratuity only if you actually attend the interview.

Thank you for your time.

Sahra Cloze
UX Designer
First and last name *
Best email address to reach you *
Best phone number to reach you *
Age *
What is your country of residence? *
Which of the following do you use as your personal mobile phone? *
How often do you post something on the following websites? *
Once a month or less
Less than once a week
Several times per week
At least once a day
In the past month, what did you want to learn? *
Thinking about the last month, how many inquiries have you made with schools that teach the aforementioned skill(s)? Please specify the skill in your response if there is more than one. *
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