EpiPen shortage survey

Thank you for sharing your recent experiences regarding the EpiPen^® shortage with us. Your information will be kept confidential and will only be used to help inform us, so we can continue to advocate on this issue.

If you have any questions, please contact us at info@foodallergycanada.ca.

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* 1. Tell us about yourself:

First name, last name

Email address

Phone number

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* 2. Where are you from?

City/town

Province

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* 3. How have you been impacted by the EpiPen shortage?

I have EpiPens that expire in August 2018.

I have EpiPens that expire shortly after August 2018.

I have expired EpiPens.

I do not have an EpiPen currently because I have (or my child has) been recently diagnosed with a food allergy.

I do not have an EpiPen currently because I cannot afford one.

Other, please explain

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* 4. Have you been able to fill your prescription?

Yes, I was able to get my full prescription.

Yes, but I was only able to get one EpiPen.

No, I was not able to get any EpiPens.

Please provide additional comments.

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* 5. How many pharmacies have you visited to fill your prescription?

More than 5

None

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* 6. Which pharmacies did you visit?

Shoppers Drug Mart/Pharmaprix

Walmart

Costco

IDA/Guardian

London Drugs

Loblaws/Superstore

Metro

Jean Coutu

Pharmasave

Rexall

Other, please list

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* 7. What did the pharmacies tell you about the shortage?

Only one device can be provided at this time because there is limited supply.

They are expecting to have supply of EpiPen soon.

They don’t know when they will have EpiPen stock again.

Other (please specify)

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* 8. Select all the reasons you need new EpiPen(s):

To replace ones that have expired or are expiring

For my child’s school

Vacation/travel

Summer camp

Other (please specify)

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* 9. Have you contacted Pfizer Canada to let them know how you have been impacted?

Yes

If no, why not?

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* 10. How do you pay for your EpiPen? Select all that apply.

Private insurance

Government program (e.g. OHIP+)

Out-of-pocket (e.g. I pay for it directly as I do not have insurance)

Other (please specify)

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* 11. Would you like to share your story if media wants to speak to families impacted by this shortage?

Yes

If Yes, please provide your contact details (name, phone number and email address) if different from information provided above.

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* 12. Please share anything else you would like us to know about this issue.

Thank you for sharing your experiences with us. We will be in touch soon with an update on this issue.