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 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 Maggie at 847-373-4104 or email maggie@lagripperesearch.com 

Thank you!

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* 1. Please fill out the following contact information:

We are currently conducting a market research study on Hepatitis (both HBV and HDV) and we are really interested in learning what life is like living with Hepatitis. As a result, we are looking for people to walk us through a year in the life – taking part in an online community and helping us to understand the highs and lows of your life over a period of 12 months. However, we realize that 12 months is a very big commitment, so we’d ask you to take part for three months and see if you enjoy it – if you do, you can keep signing up for 3-month periods, BUT if you don’t enjoy it, you can drop out at any time. 
This research is being conducted on behalf of a pharmaceutical company who manufactures medicines and treatments for HBV/HDV to help them best understand how they can help patients such as yourself.   
 
The research will take the form of an online community that we would ask you to contribute approximately one hour per month   - You will be a part of this community with other individuals diagnosed with HBV/HDV, and your participation will be anonymous (using avatars and screen names). We will never ask / collect any personal sensitive information (e.g. ethnicity, religious belief, sexual orientation, medical records).  
The community will take place through an easily accessible online platform. There will be different tasks/activities designed to make your experience as smooth and enjoyable as possible. You can share as much or as little you want about yourself and there may be other activities where you might get a chance to take part in too and, if you choose to, you could virtually meet other people like you and share your experiences. Taking this opportunity to have your voice heard would greatly help us further our research, and your participation would be hugely appreciated.  
 
 Please be aware that ELMA RESEARCH adheres to ESOMAR's, BHBIA, ABPI and Data Protection Act (UK), Market Research Society, British Healthcare Business Intelligence Association (UK) and EphMRA's market research codes of ethics and conduct. The data collected will be treated in adherence with the current legislation on personal data protection and confidentiality, will only be used for internal and research purposes and have no promotional intent whatsoever.  If you wish to see it, we will be happy to supply a copy of the privacy policy that applies to your participation in this market research study

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* 2. Online data and recordings: 
The online data and any interview we might agree to do would be audio and/or video recorded for market research and analysis purposes by members from the Elma Research team. For these purposes the recordings may be non-anonymised (non-voice distorted).  

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* 3. 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 manufacturer of medicines, details of any side effects or product complaints related to their own products that are mentioned during the course of market research. Although what you say will, of course, be treated in confidence, should you mention during the discussion a side effect or product complaint when you, or someone you know, became ill after taking one of our client’s medicines, we will need to report this, so that they can learn more about the safety of their medicines. 
 
You have the right to refuse to answer questions or withdraw at any time, including at the end of the interview following disclosure of the sponsoring company’s name.  For more information about your rights please see our privacy notice, it is available at https://www.elmaresearch.com/privacy-eng-ok/ 
 
Additionally, our client is required to report safety and adverse drug events information involving our products to the FDA upon becoming aware of such information. Therefore, we will forward any adverse event information immediately to their drug safety monitoring team. 
 
Confidentiality: 
I agree to protect all confidential information and materials disclosed to me during the study against un-authorised disclosure and will use the confidential information only for the purpose of participation in this study.  

I understand that I can withdraw my consent at any stage. 

Do you agree to proceed with the research/interview under these conditions?

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* 4. CONSENT 
  • Your responses will be used by us and the sponsoring company for market research purposes only
  • Your responses will be collated with other respondents and presented to the sponsor in aggregated or anonymized form
  • All videos, audios and pictures will be used solely in order to help members of the sponsoring pharmaceutical company to understand the research findings and will not be used in any promotional way
  • All videos, audios and pictures can only be viewed by the following department/ roles: commercial, medical, legal, and public affairs, regulatory departments and executive teams.
  • All those hearing/seeing these audios/videos/pictures agree to abide by the Market Research Society, ABPI, and all other relevant (e.g. BHBIA, EphMRA, CASRO, PMRG) Codes of Conduct for market research. 
Are you willing to proceed with the interview on this basis?

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* 5. Do you or a close member of your family work with a pharmaceutical company, market research agency or communications company?

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* 6. Have you been diagnosed with Hepatitis B (HBV) by a doctor?

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* 7. Have you been diagnosed with Hepatitis D (HDV) by a doctor?

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* 8. How long ago were you first diagnosed with the following conditions?

Years

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* 9. Have you currently ever been treated for HBV/HDV

  Currently receiving treatment Received treatment in the past 1 year Received treatment more than 1 year ago Have never received/I do not know if I have ever received treatment N/A
HBV Treatment
HDV Treatment

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* 10. If you have received treatment, where do you receive your treatment?

  In a large city A medium city/town A small town  A rural location/in the countryside N/A
HBV
HDV

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* 11. What treatments are you currently receiving or have ever received in the past for Hepatitis B (HBV) or Hepatitis D (HDV)?

  HBV HDV
Interferons (injections)
Antivirals (oral medicines)
Liver transplant

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* 12. What month and year were you born? What is your current age?

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* 13. How would you describe your household situation?

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* 14. Where were you born? (Michigan USA, Ontario Canada, etc.) 

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* 15. Are you comfortable participating in an interview where we will discuss your experience living with Hepatitis B (HBV) / Hepatitis D (HDV)?

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* 16. Are you comfortable participating in  the interview in English?

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* 17. How would you feel most comfortable communicating with us during this project?

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* 18. What sort of activities would you feel happy taking part in? This question will help us design the activities in the community in a way that reflects your preference and those of other fellow participants best.

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* 19. Which of the following statements best describes your relationship with technology and information research?

T