Hemophilia Market Research - Qualifying Questionnaire

Hemophilia Market Research Prequalifing Demographics

We are a branch of a larger market research company, whose goal is to make contact with those diagnosed and/or involved in the treatment of hemophilia (Type A, B and C). We will be looking to reach out to those who qualify in the form of online surveys and telephone discussions to further understand the needs of hemophilia patients. For this help we will pay qualified respondents for their time (up to $100). Anyone younger than 18, should have the permission of their parent/caregiver.

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

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* 1. Please note the following:

Diagnosed Patient

Care Giver

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* 2. Please indicate the diagnosis

Hemophilia A

Hemophilia B

Hemophilia C

von Willebrand

Other (please specify)

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* 3. Please note your current means of "factor" management:

Blood Serum (human)

Recombinant DNA

Combination

Other (please specify)

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* 4. Have you developed antibodies (inhibitors) against the replacement "factors"?

Yes - Current

Yes - Previously

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* 5. Please provide basic information so we can contact you when next survey is in progress. Name, Zip Code and phone number are requested NOT required.

Name:

ZIP:

Country:

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 your participation.

All information collected during the qualifying questionnaire, surveys or phone discussions are completely confidential in that your name or any other identifying information will not be shown to our clients.