We thank you for taking 5 minutes to complete this questionnaire.
 
If you are selected, you will participate in a 1-hour telephone interview, which will take place between July 15th and August 9th.

You will also be required to sign a declaration of interest form, a confidentiality form and a consent form.

Your participation will be financially compensated.

Please be assured that your information will be treated in strict confidence in accordance with applicable laws. None of this information will be made public or shared. The answers you provide will only be used for selecting patients to be interviewed about oral immunotherapy.

If you need more information, you can contact Marjo Cellier by email (marjo.s.cellier@gmail.com).

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1. Are you?

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2. What is your interest in participating at this consultation?

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3. Please provide your contact information:

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4. What is your gender?

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5. What is your age?

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6. What is your main occupation?

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7. What is your domain of work or study?

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8. What is your mother tongue?

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9.
Will you be available between July 15th and Agust 9th for a 1-hour telephone interview?

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10. During the interview, we will discuss oral immunotherapy to treat food allergies. Are you comfortable to speak about this subject in English or French?

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11. Which food allergies do you or does your child have? You can check multiple foods.

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12. How would you rate the severity of your or your child’s food allergy and its impact on your daily life and that of your family?

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13. Have you or your child received or are you currently receiving oral immunotherapy to treat the food allergy?

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14. What is your opinion on oral immunotherapy? Please indicate how much you agree with the following statements:

  Agree very much Agree Disagree Disagree very much
It seems to me that oral immunotherapy provides important benefits over a strategy of strict avoidance of allergenic foods.
It seems to me that oral immunotherapy provides no benefit compared to a strategy of strict avoidance of allergenic foods.
CONFLICTS OF INTEREST

In accordance with CSACI’s policy on conflicts of interest, we would like to ask you to complete this declaration. A conflict of interest arises when a person finds himself or herself in a situation where, objectively, his or her judgment in a specific situation is likely to be or appears to be influenced by other considerations, whether personal, financial or related to professional activities (e.g., donation, financing, support from the manufacturer of a treatment).

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15. Do you have any conflicts of interest to declare that have occurred in the last two years? This information is not used to reject questionnaires or information provided but to properly manage conflict of interests and roles when they arise.

If yes, indicate the nature of the conflict, the manufacturer or organization involved and the amounts involved, if applicable. This should include any organization directly or indirectly concerned by oral immunotherapy.


For example:

- Personal benefits, for you or a relative, received from a manufacturer or an organization interested in oral immunotherapy (donation, gifts, promotional items, travel, services, shares, stock options, etc.)

- Activities financed by a manufacturer or organization interested in oral immunotherapy (conference participation or organization, committee, research or educational grant, honorarium or salary, etc.)

- Personal or business relationships with a manufacturer or other interest groups, or an employee.

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