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 Alex at 847-533-4052 or email alex@lagripperesearch.com.

Thank you!

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* 1. Please fill out the following contact information:

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* 2. We are working in collaboration with Branding Science (BSc), an independent market research agency who have been commissioned by a pharmaceutical company to conduct this research. Taking this opportunity to have your voice heard would greatly help us further our research, and your participation would be hugely appreciated.

The purpose of the research is to understand your reaction to a potential clinical trial related to eye diseases. Our wish is to identify any challenges you may face throughout the clinical trial, to make it easier for future patients to participate. There is a 30-minute pre-task which will involve reading a document, which has an auditory explanation along with a short video about the proposed trial. This will be followed by a 75-minute interview (or 90-minute interview alongside a care partner (nAMD only)) conducted via Zoom or regional equivalent. For those who participate we will provide a payment for the interview.

Do you want to continue?

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* 3. PRIVACY
The research will comply with your local Data Protection Laws and Market Research Society’s Code of Conduct including BHBIA, ESOMAR, EphMRA, Insights Association and all other relevant national codes of practice.

You will remain anonymous unless you give permission to be identified.
You have the right to refuse to answer questions or to withdraw at any time.

Any information you provide us with will be treated as confidential, it will be combined with feedback from others like yourself. The aim of this market research is to gain your views and is not intended to be promotional and no one will try to sell you anything.
Your information will only be used for this purpose and will not be passed on to any third party without your permission.

You can find a full copy of Branding Science’s privacy notice online; this explains all your data protection rights and is available at http://www.branding-science.com/privacy/. An electronic copy in PDF format is also available upon request.

DISCLOSURE OF ADVERSE EVENT REPORTING
Different patients sometimes respond in different ways to the same medicine, and some side effects may not be discovered until many people have used a medicine over a period of time. For this reason, we are now required to pass on to our client, who is a pharmaceutical company, details of any side effects/product complaints related to their own products that are mentioned during market research.

Although what you say will, of course, be treated in confidence, should you mention during the discussion a side effect when you, or someone you know, became ill after taking one of our client’s medicines, or a problem you have had with one of our clients medicines we will need to report this, so that they can learn more about the safety of their medicines.

In such a situation you will be asked if you are willing to waive the confidentiality given to you under the Market Research Codes of conduct specifically in relation to that adverse event/ product complaint.
Everything else you say during the interview will continue to remain confidential, and you will still have the option to remain anonymous if you so wish.

Do you have any questions? Can we continue with the interview on this basis?

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* 4. OBSERVATION AND RECORDING
The discussion will be:
  1. Audio and video recorded for analysis at a later stage. This is for the use of BSc and the recruitment agency only. The recording may be analysed by staff of BSc who are operating outside the European Economic Area (“EEA”), or the country where the interview takes place.
  2. Listened to as it happens by people from the client company at their offices in DE, UK, PL, ESP and US.
  3. Video recorded and watched as it happens by people from the client company at their offices in DE, UK, PL, ESP and US. Access to the recording will only be available to specific personnel via a password protected link. It will not be shared with anyone else or used for any other purpose without your permission.
  4. Audio and video recorded but listened at a later date by people from the client company at their offices in DE, UK, PL, ESP and US. Access to the audio recording will only be available to specific personnel via a password protected link. It will not be shared with anyone else or used for any other purpose without your permission.
Branding Science and sponsor company staff may be based outside the European Economic Area (“EEA”), or the country where the interview takes place. All staff have confirmed their agreement to follow Observer Guidelines. Adequate data protection measures will be put in place to comply with the Data Protection Laws of the country in which the interview took place.

The screening process to verify whether you qualify or not for this market research study may involve profiling and segmenting based on your anamnesis (disease type, therapy area, etc…) and making decision based on your answers.

RECONTACT
We may want to further explore your responses to some of the questions answered. Would you be prepared to be re-contacted by LaGrippe Research within 3 months?

Are you happy to proceed with this screening interview on this basis?

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* 5. Are you, or is any member of your household employed by:

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* 6. What is your gender?

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* 7. Have you or the person you care for received a diagnosis of the following conditions from an ophthalmologist?

  • Neovascular age-related macular degeneration (nAMD / wet age-related macular degeneration)
  • Diabetic macular edema (DME)

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