Availability of Prescribed Epinephrine Survey

1.Have you been unable to fill or refill a prescription for EpiPen, EpiPen Jr, or generic EpiPen or EpiPen Jr. within the last two months, due to a lack of adequate supply at your pharmacy?

I could not fill it at all

I could fill it, but only partially

I was able to fill it completely- SKIP TO QUESTION 3

2.If you could not fill your prescription, were you able to with an alternate brand, and if so, which one?

Yes

No

If yes, specify below.

3.Which device(s) were you trying to obtain?

4.What pharmacy did you visit for this purchase?

Other (please specify)

5.In what state is the pharmacy located?

6.Comments?