Esophageal Cancer Insights Pre-screener to be considered Question Title * 1. Address Name Company City/Town State/Province Country LinkedIn or Social Media Profile Email Address Phone Number OK Question Title * 2. Please indicate which of the below applies to you. Please select all that apply. I have been diagnosed with esophageal cancer by a healthcare provider. I have a primary active role in the care of someone who has been diagnosed with esophageal cancer by a healthcare provider (e.g., receiving info on their behalf, helping with medications and doctor visits). I support someone close to me (such as a relative or partner) who has been diagnosed with esophageal cancer by a healthcare provider but do not have a primary active role in their care. Neither have nor take care of/support someone who has been diagnosed with esophageal cancer. OK Question Title * 3. Do you know what type of esophageal cancer it is? Esophageal adenocarcinoma Esophageal squamous cell carcinoma I don’t know OK Question Title * 4. Do you know the stage of the esophageal cancer you or your loved one has been diagnosed with? Stage I Stage II Stage III Stage IVA Stage IVB I don’t know OK Question Title * 5. Can the esophageal cancer you or your your loved one has been diagnosed with, be entirely removed with surgery? Yes No I don’t know OK Question Title * 6. What is your and your loved one’s current age? OK Question Title * 7. What is your gender? Male Female Prefer not to say OK Question Title * 8. Please select your ethnic background? American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Prefer not to say Other (please specify) OK Question Title * 9. How long ago was you or your loved one diagnosed with esophageal cancer? OK Question Title * 10. Is you or your loved one currently receiving, or has previously received, any of the following treatments for esophageal cancer? Current Treatment Previous Treatment Chemotherapy Chemotherapy Current Treatment Chemotherapy Previous Treatment Nivolumab (Opdivo) Nivolumab (Opdivo) Current Treatment Nivolumab (Opdivo) Previous Treatment Pembrolizumab (Keytruda) Pembrolizumab (Keytruda) Current Treatment Pembrolizumab (Keytruda) Previous Treatment None of the above/ I do not remember None of the above/ I do not remember Current Treatment None of the above/ I do not remember Previous Treatment OK Question Title * 11. On a scale of 1 to 10 where 1 is not at all comfortable and 10 is completely comfortable, how comfortable are you in sharing your or your loved one’s esophageal cancer story? 0 10 Clear i We adjusted the number you entered based on the slider’s scale. OK Question Title * 12. On a scale of 1 to 10 where 1 is not at all comfortable and 10 is completely comfortable, how comfortable are you with using technology like a personal computer and smart phone to find images and respond to questions? 0 10 Clear i We adjusted the number you entered based on the slider’s scale. OK Question Title * 13. Are you willing complete a couple of exercises prior to and after the telephone interview? Yes No OK Question Title * 14. Do you have any employment, professional or other legal obligations which may restrict you from openly discussing your views on therapies for esophageal cancer? Yes No OK Question Title * 15. Are you or is any member of your family directly employed by any pharmaceutical company, government regulatory agency, pharmaceutical, advertising, media or market research agency? Yes No OK Question Title * 16. Our client would like the research to include one or more video recordings of you telling us your and your loved one’s story. Your face may to be visible during the recording. You are not required to disclose any information about yourself other than what you are willing to share about your loved one’s esophageal cancer story. Are you willing for us to share such recordings with our client so that they have a deeper understanding of the experience of individuals with esophageal cancer directly from their voice or video recording? Yes No OK Question Title * 17. We are required to pass on to our client details of adverse events that are mentioned during the course of market research, as the pharmaceutical company commissioning this research has a legal obligation to report this as part of their ongoing benefit risk management. Although what you say will, of course, be treated in confidence, should you raise an adverse event that you (or your loved one) experienced during the discussion, we will need to report this, even if it has already been reported by you directly to the company or the regulatory authorities. Are you willing to participate in the interview on this basis? Yes No OK Question Title * 18. In case you mention an adverse event during this market research, we would file a report without giving any of your details, but if the Drug Safety Department requires more information, would you be willing to waive the confidentiality given to you under the Market Research Codes of conduct specifically in relation to that adverse event, so they can contact you directly for further information? Please note that if you provide your name during the Adverse Event reporting, this will not be linked in any way to the responses given during the market research and everything else you say during the course of the interview will continue to remain confidential. Yes No OK Question Title * 19. As the patient, we would be happy to have your actively engaged caregiver participate in this interview with you. Are you willing to share the following with your care giver and have him/her as a co-respondent No, I prefer to do this on my own Yes, that is fine with me. OK DONE
