Cystic Fibrosis (CF) Qualifying Questionnaire

We are a branch of a larger market research company, whose goal is to make contact with as many people diagnosed or caregiver in the treatment of Cystic Fibrosis (CF). We will be looking to reach out to those who show interest in the form of online surveys and telephone discussions to understand the needs of CF patients. When contacted and qualified we will pay respondents for their time (up to $100).

This project is solely concerned with marketing research and there will be no attempts to sell you anything or influence your pharmaceutical or treatment options in any way.

All information collected during the surveys or phone discussions are completely confidential in that your name or other identifying information will not be shown to our clients.

Question Title

* 1. Please indicate whether you are a CF patient or caregiver?

Patient

Caregiver

Other (please specify)

Question Title

* 2. Are you / your child currently being treated, or in the past have you been treated, with Kalydeco?

YES

Question Title

* 3. Which of the following mutations do you / your child have (select all that apply):

a. G551D

b. G1244E

c. G1349D

d. G178R

e. G551S

f. S1251N

g. S1255P

h. S549N

i. S549R

j. R117H

k. two copies of the F508del mutation (F508del/F508del)

l. one copy of the F508del mutation (F508 del)

m. another mutation not on this list

n. I don’t know

Question Title

* 4. How old are you (only if you have CF) and/or your child/children who has CF (again, select all that apply e.g., if you and your child have CF):

a. Under 2 years old

b. Between 2 and 5 years old

c. 6 – 14 years old

d. 15 – 17 years old

e. 18 – 25 years old

f. 26+ years old

Question Title

* 5. Check current or past medication -

Aztreonam - (Cayston™)

Azithromycin – (Zithromax™, ZMax™)

Ciprofloxacin – (Cipro™, Proquin™)

Colistin -

Tobramycin – (TOBI™)

Ivacaftor – (Kalydeco™)

Drug Trial - Note in "Other" specifics

Other (please specify)

Question Title

* 6. Please complete information so we can contact you when interview is scheduled for those that qualify. Name, Address and Phone # are optional at this time.

Name:

Address:

City/Town:

State:

ZIP:

Email Address: *

Phone Number:

Thank you very much for taking the time to fill out this short questionnaire. We are collecting basic information to match individuals with specific survey requirements in order to invite your participation.