HIV/AIDS (MR)

Qualifying Questionnaire for HIV/AIDS Surveys

We are a branch of a larger market research company, whose goal is to make contact with individuals diagnosed with HIV/AIDS. 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 a diagnosed HIV/AID's patient or caregiver of a diagnosed patient?

Patient

Caregiver

Question Title

* 2. Please identify which of the following “fixed-dose combination” medication(s) have/are you utilizing in the management of HIV/AIDS?

Select those that apply to current and past management.

	Current	Past
Atripla®	Atripla® Current	Atripla® Past
Combivir®	Combivir® Current	Combivir® Past
Complera®	Complera® Current	Complera® Past
Epzicom® or Kivexa®	Epzicom® or Kivexa® Current	Epzicom® or Kivexa® Past
Kaletra®	Kaletra® Current	Kaletra® Past
Stribild®	Stribild® Current	Stribild® Past
Trizivir®	Trizivir® Current	Trizivir® Past
Truvada®	Truvada® Current	Truvada® Past
None of the above	None of the above Current	None of the above Past

Other (please specify)

Question Title

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

Name:

City/Town:

State/Province:

ZIP/Postal Code: *

Country:

Email Address: *

Phone Number:

Question Title

* 1. Are you a diagnosed HIV/AID's patient or caregiver of a diagnosed patient?

Question Title

* 2. Please identify which of the following “fixed-dose combination” medication(s) have/are you utilizing in the management of HIV/AIDS?Select those that apply to current and past management.

Question Title

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

Question Title

* 2. Please identify which of the following “fixed-dose combination” medication(s) have/are you utilizing in the management of HIV/AIDS?

Select those that apply to current and past management.