Thank you for your interest in our upcoming study. Please fill out the following preliminary questions below. Once completed, if you qualify, we will follow up with you shortly after 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 Maggie@lagripperesearch.com

Thank you!

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* 1. Please fill out the following contact information:

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* 2. An internet connection will be required for the interview. For paired webcam interviews and webcam focus groups, you will need to have a working webcam. Please be sure to have a laptop or desktop computer available to use during the interview; tablets and smartphones will not be acceptable to use on the internet platform.

Are you happy to participate based on the above?

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* 3. PRIVACY
We comply with privacy, data use, data protection and informed consent laws and regulations governing your personal information. The research will comply with MR guidelines. Any information you provide us with will be treated as confidential, it will be combined with feedback from others like yourself.  You will remain anonymous unless you give permission to be identified.  Your information will only be used for market research purposes and will not be passed to any other organisation without your permission.  You have the right to refuse to answer questions or withdraw at any time.  A consent form will be provided explaining what if any personal data will be kept, for how long, for what purpose, who will have access to it and who you may contact with any questions. We need your consent in order for us to collect and use any information about you. 

Are you happy to proceed on this basis?

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* 4. Consents 
We act in accordance with all relevant codes of conduct and legislation for anonymity in market research. The aim of market research is to gain your views and is not in any way promotional. You can withdraw from the study at any time and withhold information as you see fit.  To participate in this study, you must acknowledge and agree to the following terms regarding study requirements and the information you will provide during the study: 
 
Study Sponsorship This study is being conducted on behalf of a sponsoring global biopharmaceutical company  
 
Study Withdrawal You can withdraw from the study at any time and withhold information as you see fit. Should you decide to withdraw from the study, however, we reserve the right to withhold all or a portion of the payment that would otherwise be made for your participation. 
 
Confidentiality of Study Information The purpose of this study is purely to gain your feedback and in no way is a marketing or sales pitch by this market research company or our Sponsor.  By participating, you agree to hold confidential any information you may obtain through this study, and specifically agree not to discuss with others, or attempt to print, copy, or distribute any of the information contained herein. Please note that during this study, you may be exposed to product information that is investigational in nature and may or may not be approved by the appropriate government agencies for use in clinical practice.  
 
Recording/Observing All interviews are audio recorded and research colleagues and/or the Sponsor may be viewing or listening to the interview and/or may review the recording at another time. This interview is also being livestreamed via a secure internet connection to research colleagues and/or the Sponsor who are viewing remotely. The study that you will be participating in is being conducted as double-blind. This means that neither you nor the Sponsor will be told each other’s identity. 

Are you willing to proceed under the terms described?

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* 5. Consents Continued.. 

Pharmacovigilance and Product Technical Complaints Reporting 
We are required to pass on to the Sponsor details of adverse events, other pharmacovigilance data (also known as PV data), and/or product technical complaints pertaining to their products that are mentioned during the market research study.  
 
"Adverse Event" or “AE” refers to any untoward medical occurrence in a patient who takes or uses a product, and which does not necessarily have a causal relationship with that product.  An adverse event can therefore be any unfavourable and unintended sign (including an abnormal laboratory finding, for example), symptom, or disease, temporally associated with the use of such a product, whether or not considered related to that product. 
 
“Pharmacovigilance Data” or “PV Data” includes any adverse event (serious or not), any incident (serious or not), or any of the following special situations (with or without adverse events):  any report of misuse; any medication error; any off-label use (intentional use outside the labelled indication); any overdose (intentional or not); any drug abuse, dependence, addiction, (withdrawal syndrome); any lack of efficacy; any drug exposure during pregnancy or child exposure during breastfeeding or conception (whether from the male or female); any occupational exposure (unintentional exposure during work); accidental exposure; unexpected therapeutic benefit; any suspected transmission of infectious agents; and/or suspected drug interactions involving active ingredients or their metabolites.   
 
“Product complaint”, “Product Technical Complaint” or “PTC” refers to any written, electronic, or oral communication that alleges deficiencies related to the identity, quality, durability, reliability, safety, efficacy or performance of a product, device, its packaging, or any written leaflet or other information provided with such product or device, after it is released for distribution.   
 
Should you mention during the discussion an adverse event or other PV Data or product technical complaint regarding yourself or a specific patient about a specific product, we will need to report this even if it has already been reported by you directly to the company or to regulatory authorities. 
 
In such a situation, you will be asked whether you are willing to waive the anonymity given to you under the ICC/ESOMAR International Code on Market and Social Research practice and the EphMRA Code of 
Conduct specifically in relation to that adverse event/product technical complaint. If you are willing to waive your anonymity, your name and contact information will be provided to the research Sponsor, who may report it to the U.S. Food and Drug Administration and you may be contacted for follow-up questions regarding the adverse event, other PV Data, and/or product technical complaint.  If you are not willing to waive your anonymity, the adverse event, other PV Data, and/or product technical complaint will be reported anonymously.  Regardless, everything else you say during the study will continue to remain anonymous.  
 
Are you willing to proceed under the terms described?

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* 6. These first few questions will be regarding to you (patient/caregiver), then we will dive into questions about your child/children.

What month and year were you born? What is your current age?

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* 7. Which of the following best describes your gender?

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* 8. Please tell me which of the following best describes your ethnicity?
Select all that apply

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* 9. What state do you reside in?

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* 10. Are you a primary caregiver for any children under the age of 18?

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* 11. The next few questions we will be asking about your child/children. If you have more than one child, please assign each child a number and remain consistent throughout the next few questions.

Please indicate the age and gender of the child/children you care for?

  Age Gender
Child 1
Child 2
Child 3
Child 4

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* 12. Please tell me which of the following best describes the ethnicity of the child/children you care for?  This question is for classification purposes only.
Select all that apply

  Caucasian / White Black or African American Hispanic or Latino Asian American Indian or Alaskan native Native Hawaiian or other Pacific Islander Other N/a
Child 1
Child 2
Child 3
Child 4

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* 13. Often people who work for businesses related to certain types of products or services can bring  insight and understanding to our work.  At any time in the past year, have you or anyone in your immediate family worked in any of the following businesses?

Select all that apply

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* 14. Has your child / have your children been diagnosed by a healthcare professional with any chronic/on-going health conditions? If so which ones?
Select all that apply

  Allergy Atopic Dermatitis / Eczema Asthma Chronic Urticaria / chronic hives Eosinophilic esophagitis (EoE) Type 1 Diabetes Type 2 Diabetes Hemophilia A Hemophilia B NONE N/A
Child 1
Child 2
Child 3
Child 4

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* 15. Has this doctor ever described your child’s asthma in one of the following ways:

  Mild Moderate Severe (difficult to treat) Unsure N/A
Child 1
Child 2
Child 3
Child 4 

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* 16. Using these same categories, how would you personally describe your child’s asthma:

  Mild Moderate Severe (difficult to treat) Unsure N/A
Child 1
Child 2
Child 3
Child 4 

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* 17. Which of the following best describes your current primary health insurance provider for your child / children diagnosed with asthma?
Select all that apply

  Not insured Private insurance provided by my employer Private insurance provided by my school Private insurance that I did not obtain through my employer or school Medicare Medicaid Veterans Administration (VA) This child is not diagnosed with asthma N/a
Child 1
Child 2
Child 3
Child 4

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* 18. Is your child / are your children currently taking any medication prescribed by a physician on an active or frequent basis to manage their asthma?
Select all that apply

  Yes No This child is not diagnosed with asthma N/a
Child 1
Child 2
Child 3
Child 4

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* 19. Now we would like to ask about your child/children's treatment.
We will ask each individually

We would like to know (1) what they are CURRENTLY taking on an active or frequent basis (2) What they have taken in the PAST and are no longer taking.

Child 1: 

  CURRENTLY Taking  Taken in PAST, not currently 
Methylprednisolone
Prednisone
Qvar (beclomethasone)
Pulmicort (budesonide)
Alvesco (ciclesonide)
Aerobid (flunisolide)
Arnuity (fluticasone)
Flovent Diskus (fluticasone)
Asmanex Twisthaler (mometasone)
Flutiform (fluticasone + formoterol)
Relvar Ellipta (fluticasone + vilanterol)
Seretide (fluticasone + salmeterol)
Advair (fluticasone + salmeterol)
Symbicort (budesonide + formoterol)
Dulera (mometasone + formoterol)
Atrovent (ipratropium)
Spiriva Respimat (tiotropium)
Serevent (salmeterol) 
Foradil (formoterol)
Accolate (zafirlukast)
Singulair (montelukast)
Zyflo (zileuton)
Xolair (omalizumab)
Nucala (mepolizumab)
Dupixent (dupilumab)
Tezspire (tezepelumab)
None of the above 

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* 20. Child 2:  We would like to know (1) what they are CURRENTLY taking on an active or frequent basis (2) What they have taken in the PAST and are no longer taking.

IF YOU DONT HAVE ANY MORE CHILDREN OR THIS CHILD DOES NOT HAVE ASTHMA PLASE SELECT N/A AT THE BOTTOM

  CURRENTLY Taking  Taken in PAST, not currently 
Methylprednisolone
Prednisone
Qvar (beclomethasone)
Pulmicort (budesonide)
Alvesco (ciclesonide)
Aerobid (flunisolide)
Arnuity (fluticasone)
Flovent Diskus (fluticasone)
Asmanex Twisthaler (mometasone)
Flutiform (fluticasone + formoterol)
Relvar Ellipta (fluticasone + vilanterol)
Seretide (fluticasone + salmeterol)
Advair (fluticasone + salmeterol)
Symbicort (budesonide + formoterol)
Dulera (mometasone + formoterol)
Atrovent (ipratropium)
Spiriva Respimat (tiotropium)
Serevent (salmeterol) 
Foradil (formoterol)
Accolate (zafirlukast)
Singulair (montelukast)
Zyflo (zileuton)
Xolair (omalizumab)
Nucala (mepolizumab)
Dupixent (dupilumab)
Tezspire (tezepelumab)
None of the above 
N/a

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* 21. Child 3:We would like to know (1) what they are CURRENTLY taking on an active or frequent basis (2) What they have taken in the PAST and are no longer taking.

IF YOU DONT HAVE ANY MORE CHILDREN OR THIS CHILD DOES NOT HAVE ASTHMA PLASE SELECT N/A AT THE BOTTOM

  CURRENTLY Taking  Taken in PAST, not currently 
Methylprednisolone
Prednisone
Qvar (beclomethasone)
Pulmicort (budesonide)
Alvesco (ciclesonide)
Aerobid (flunisolide)
Arnuity (fluticasone)
Flovent Diskus (fluticasone)
Asmanex Twisthaler (mometasone)
Flutiform (fluticasone + formoterol)
Relvar Ellipta (fluticasone + vilanterol)
Seretide (fluticasone + salmeterol)
Advair (fluticasone + salmeterol)
Symbicort (budesonide + formoterol)
Dulera (mometasone + formoterol)
Atrovent (ipratropium)
Spiriva Respimat (tiotropium)
Serevent (salmeterol) 
Foradil (formoterol)
Accolate (zafirlukast)
Singulair (montelukast)
Zyflo (zileuton)
Xolair (omalizumab)
Nucala (mepolizumab)
Dupixent (dupilumab)
Tezspire (tezepelumab)
None of the above 
N/a

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* 22. Child 4:  We would like to know (1) what they are CURRENTLY taking on an active or frequent basis (2) What they have taken in the PAST and are no longer taking.

IF YOU DONT HAVE ANY MORE CHILDREN OR THIS CHILD DOES NOT HAVE ASTHMA PLASE SELECT N/A AT THE BOTTOM

  CURRENTLY Taking  Taken in PAST, not currently 
Methylprednisolone
Prednisone
Qvar (beclomethasone)
Pulmicort (budesonide)
Alvesco (ciclesonide)
Aerobid (flunisolide)
Arnuity (fluticasone)
Flovent Diskus (fluticasone)
Asmanex Twisthaler (mometasone)
Flutiform (fluticasone + formoterol)
Relvar Ellipta (fluticasone + vilanterol)
Seretide (fluticasone + salmeterol)
Advair (fluticasone + salmeterol)
Symbicort (budesonide + formoterol)
Dulera (mometasone + formoterol)
Atrovent (ipratropium)
Spiriva Respimat (tiotropium)
Serevent (salmeterol) 
Foradil (formoterol)
Accolate (zafirlukast)
Singulair (montelukast)
Zyflo (zileuton)
Xolair (omalizumab)
Nucala (mepolizumab)
Dupixent (dupilumab)
Tezspire (tezepelumab)
None of the above 
N/a

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