Myelodysplastic Syndromes (MDS)

MDS Market Research Prequalifing Questionnaire

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Individuals meeting project qualification and completing invited 1 hour phone/internet survey will be paid (up to $250).

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.

We are a branch of a larger market research company, whose goal is to make contact with as many people diagnosed or involved in the treatment of Myelodysplastic Syndromes (MDS). We will be looking to reach out to those interested in the form of online surveys and telephone discussions to understand the needs of MDS patients. When contacted and qualified we will pay respondents for their time (up to $250).

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

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* 1. Please provide your sex

	Male	Female
Sex	Sex Male	Sex Female

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* 2. Please provide you age range:

	20-35	36-50	51-65	66-up
Age	Age 20-35	Age 36-50	Age 51-65	Age 66-up

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* 3. If known please indicate the classification of your MDS diagnosis.

De novo Myelodysplastic Syndromes

Secondary Myelodysplastic Syndromes

Other (please specify)

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* 4. Please indicate the treatments you have utilized, if any, for the treatment of your MDS.

Epogen® (Epoetin alfa)

Aranesp® (darbepoetin alfa)

Vidaza® (azacitidine)

Dacogen® (decitadine)

Revlimid® (lenalidome)

Bone marrow stem cell transplant

Other (please specify)

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* 5. Have you ever received Iron Chelation Therapy (Reversal of iron overload) as part of your treatment?

YES

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.

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* 6. Please provide basic demographic information:

Name, phone # requested – not required.

Name:

City/Town:

State:

ZIP:

Country:

Email Address: *

Phone Number:

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* 1. Please provide your sex

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* 2. Please provide you age range:

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* 3. If known please indicate the classification of your MDS diagnosis.

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* 4. Please indicate the treatments you have utilized, if any, for the treatment of your MDS.

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* 5. Have you ever received Iron Chelation Therapy (Reversal of iron overload) as part of your treatment?

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* 6. Please provide basic demographic information:Name, phone # requested – not required.

* 6. Please provide basic demographic information:

Name, phone # requested – not required.