Screening Survey

Thank you for your interest in our upcoming study. Please fill out the following preliminary questions below. Once completed, we will follow up with you shortly after regarding your eligibility in the project and if qualified, to discuss details and scheduling. If you do not qualify, we will email you at the end of the project thanking you for your time and asking if you would be interested in future projects that you may qualify for.

If you have any questions, please contact Maggie at 847-373-4104 or email maggie@lagripperesearch.com

Thank you!

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* 1. Please fill out the following contact information:

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* 2. INTRODUCTION
We are working on this study with Avalere Health. The purpose of the research is to speak with those who are taking medication for a mental health condition and suffering with involuntary movement symptoms.

If you are interested in taking part, I would like to ask you some questions to see if you fit the profile of respondents we are looking to participate. Before we go through these questions, there is some information I need to cover with you first.

We are conducting market research on behalf of a pharmaceutical company. However, this is strictly market research, and therefore we are not trying to sell or promote anything. We are just interested in hearing your thoughts, opinions and experiences relating to the topic of interest. The company that is sponsoring the market research does not see or hold any information about the respondents. Please note, you may withdraw at any stage in the process, or withhold information as you deem necessary.

Before we start, I want to reassure you that we act in accordance with all relevant market research codes of conduct regarding anonymity and confidentially in the US.

If the market research study is appropriate, we will invite you to take part in a 60-minute web-assisted interview.

We would like to offer you $125 to thank you for your time and help.

Does this sound like something you might be interested in?

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* 3. ASSISTANCE DURING INTERVIEWS
Should you decide to take part in this interview, would you require any breaks or assistance during the process?

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* 4. AUDIO
The interview will be audio recorded to support our analysis process and as part of quality control, but these recordings will not be passed onto the client without your prior consent.

LIVE VIEWING
The interviews may be heard online by members of Avalere Health or the sponsoring company via a secure weblink. Your details and identity remain completely confidential throughout this process, and your anonymity is assured. To allow the sponsor / Avalere Health team to listen, we need your prior consent.

Would you be happy for members of the sponsoring company / Avalere Health to listen live to the interview via a secure weblink? If you would not like the sponsor / Avalere Health team to listen live, this does not preclude you from the research.

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* 5. PRIVACY POLICY
The Avalere Health privacy policy can be found here: https://avalerehealth.com/privacy-policy/

ADVERSE EVENTS
We are required to pass on to the sponsor the details of any adverse events (including actual and potential adverse events or product complaints, etc.) that are mentioned during the course of this market research. Although what you share will be treated in confidence, should you include an adverse event relating to yourself or a specific patient in your responses, we will need to report the adverse event directly to the company or the regulatory authorities using the normal reporting processes, even if you have already reported it directly to the company or the regulatory authorities.

In such a situation you will be asked whether or not you are willing to waive the confidentiality given to you under the market research codes of conduct specifically in relation to that adverse event. Everything else you say during the course of the interview will continue to remain confidential, and you will still have the option to remain anonymous if you so wish.

Are you happy to proceed on this basis?

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* 6. Are you or any of your family members currently employed by or have a commercial affiliation with any of the following? Select all that apply.

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* 7. If you selected ANY of the above industries, please specify job title and who works there.

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* 8. Have you participated in any market research relating to any of the following conditions in the past 3 months? Select any that apply for the last 3 months.

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* 9. Have you ever been diagnosed by a health care professional with any of the following mental health condition(s)? Select all that apply.

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* 10. Where do you go to receive medical care for your condition(s) mentioned above from a health care professional? Please select all that apply

Note, we are using the following definitions to define the below settings:
  • In-patient hospital: A hospital where you stay overnight (or longer) for treatment, or recovery
  • Outpatient hospital: A hospital or clinic where you go for care but don’t need to stay overnight
  • Long-term care facility (LTC): A place where people live if they need ongoing daily help with medical care or personal needs
  • Community Mental Health Center (CMHC): A local clinic that provides counselling, therapy, and mental health services to people in the community
  • Movement Disorder Center: A specialized clinic that focuses on conditions like that cause movement problems
  • VA Medical Center: A hospital or clinic run by the Department of Veterans Affairs that provides care for military veterans
  • Private office: A doctor’s own office or clinic where they see patients one-on-one

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* 11. Which type of health care professional (HCP) do you primarily see specifically for the management of this condition? Please select the HCP that is most involved in your care.

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* 12. How often do you see this doctor?

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* 13. Which of the oral medications are you currently taking or have you taken in the past 3 years?

  Currently use Taken in the past 3 years but not currently
Abilify (aripiprazole)
Clozaril, Fazaclo (clozapine)
Cobenfy (xanomeline and trospium chloride)
Fanapt (iloperidone)
Geodon (ziprasidone)
Haldol (haloperidol)
Invega (paliperidone)
Latuda (lurasidone)
Loxitane (loxapine)
Navane (thiothixene)
Orap (pimozide)
Prolixin (fluphenazine)
Rexulti (brexpiprazole)
Risperdal (risperidone)
Saphris (asenapine)
Seroquel (quetiapine)
Stelazine (trifluoperazine)
Thioridazine (thioridazine)
Thorazine (chlorpromazine)
Trilafon (perphenazine)
Vraylar (cariprazine)
Zyprexa (olanzapine)

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