HCV - Market Research Survey

We are a branch of a larger market research company, whose goal is to make contact with individuals and caregivers of those diagnosed with HEPATITIS C. In the coming months, we will reach out to those interested in participating in on-line surveys and/or telephone discussions to help understand the treatment decision process. When contacted and qualified we will pay respondents for their time (up to $100).

This project is solely concerned with marketing research and there will be no attempts to sell you anything or influence your pharmaceutical or treatment options in any way

Our clients range from not-for-profit organizations, advertising agencies, advocacy groups and pharmaceutical companies. We work with them as an independent research company to gather the opinions of individuals closest to various disease groups. We have worked in a number of different disease areas including diabetes, autism, Fragile X, hemophilia and many more.

All information collected during the surveys or phone discussions will be completely confidential in that we will not show your name or any other identifying information to our clients.

Question Title

* 1. Are you the patient or caregiver?

Patient

Caregiver

Question Title

* 2. Has a “Hepatitis” been diagnosed by a physician?

Yes

Question Title

* 3. If known, please identify the HCV genotype you have been diagnosed?

Question Title

* 4. Please identify which of the following medication(s) you have/are you utilizing for hepatitis C treatment.
Select those that apply to current and past treatment.

	CURRENT	PAST
Pegylated interferon®	Pegylated interferon® CURRENT	Pegylated interferon® PAST
ribavirin	ribavirin CURRENT	ribavirin PAST
sofosbuvir (Sovaldi®)	sofosbuvir (Sovaldi®) CURRENT	sofosbuvir (Sovaldi®) PAST
Boceprevir( Victrelis®)	Boceprevir( Victrelis®) CURRENT	Boceprevir( Victrelis®) PAST
Telaprevir (Incivek® and Incivo®)	Telaprevir (Incivek® and Incivo®) CURRENT	Telaprevir (Incivek® and Incivo®) PAST

Other (please specify)

Question Title

* 5. Please provide basic information for us to contact you when telephone/internet survey is scheduled. Name, address and phone numbers are optional.

Name:

Address 1:

Address 2:

City/Town:

State/Province:

ZIP/Postal Code:

Country:

Email Address: *

Phone Number:

Question Title

* 1. Are you the patient or caregiver?

Question Title

* 2. Has a “Hepatitis” been diagnosed by a physician?

Question Title

* 3. If known, please identify the HCV genotype you have been diagnosed?

Question Title

* 4. Please identify which of the following medication(s) you have/are you utilizing for hepatitis C treatment. Select those that apply to current and past treatment.

Question Title

* 5. Please provide basic information for us to contact you when telephone/internet survey is scheduled. Name, address and phone numbers are optional.

Question Title

* 4. Please identify which of the following medication(s) you have/are you utilizing for hepatitis C treatment.
Select those that apply to current and past treatment.