Non Small Cell Lung Carcinoma (NSCLC) (MR)

We are a branch of a larger market research company, whose goal is to make contact with individuals and/or caregivers for those diagnosed with NSCLC. We will be looking to reach out to those who show interest in the form of online surveys and telephone discussion to understand the needs of NSCLC patients. When contacted, qualified and survey completed, we will pay respondents for their time (up to $100).

Identifying personal information collected during the surveys or phone discussions are completely confidential and will not be shown to our clients.

Question Title

* 1. Please note age when diagnosed.

<30 Years

31 - 40 Years

41 - 50 Years

51 - 60 Years

61 - 70 Years

71 - 80 Years

>80 Years

Question Title

* 2. Please note year diagnosed (enter 4-digit year, for example, 2010)

Question Title

* 3. If known please indicate type of NSCLC diagnosed.

Squamous (SCC)

Large cell (NCLC)

Adenocarcinoma

not otherwise specified (NOA)

Other (please specify)

Question Title

* 4. If known please indicate Stage of NSCLC?

lll

Unknown

Question Title

* 5. Please provide demographic information. Name, Phone and Zip are optional at this time.

Name:

ZIP:

Email Address: *

Phone Number:

Thank you very much for taking the time to fill out this short questionnaire. We are collecting basic information to match individuals with specific survey requirements in order to invite qualified individuals.