Opinion Study Survey

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* 1. Contact Info

Name

Phone

E-Mail

Gender

Age

State

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* 2. The research may be observed, recorded, and listened to in person/on location or remotely from their offices for purposes of understanding their condition and the market for research purposes by representatives from HawkPartners and the sponsor. Those representatives must respect the confidentiality of all information collected in market research interviews/groups and you will not be marketed to on the basis on your participation in this research. The information that you provide is confidential and your identity will never be revealed to the sponsor unless required by law only for the reporting of a safety-related issue. All answers will be summarized and reported, in total, with all other study participants. You have the right to refuse to answer any question or to withdraw from participation at any time. HawkPartners will comply with all applicable data protection and privacy laws, together with any applicable guidelines (including relevant associations) and applicable global codes of practice.

Consent for Audio / Video Recording in Healthcare Market Research

This consent is designed to gain your permission to audio/video record for the purposes of obtaining feedback on marketing communications materials. By signing this form, you agree to the following terms for you:

By checking the boxes below, you are agreeing to these consents for audio recording related to this specific Market Research:

	yes	no
I consent to be audio recorded for the purposes of optimizing marketing communications materials	I consent to be audio recorded for the purposes of optimizing marketing communications materials yes	I consent to be audio recorded for the purposes of optimizing marketing communications materials no
I understand that my voice will no be altered	I understand that my voice will no be altered yes	I understand that my voice will no be altered no

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* 3. Your Information will only be used for the purposes shared in this consent:

	yes	no
I acknowledge that the audio will be shared with the Sponsor in a manner that does not reveal additional identifying information beyond my first name and potentially voice.	I acknowledge that the audio will be shared with the Sponsor in a manner that does not reveal additional identifying information beyond my first name and potentially voice. yes	I acknowledge that the audio will be shared with the Sponsor in a manner that does not reveal additional identifying information beyond my first name and potentially voice. no
I understand that my full name and contact details will remain confidential and will not be shared in connection with the audio for purposes of understanding their condition and the market	I understand that my full name and contact details will remain confidential and will not be shared in connection with the audio for purposes of understanding their condition and the market yes	I understand that my full name and contact details will remain confidential and will not be shared in connection with the audio for purposes of understanding their condition and the market no
I grant permission for the audio to be viewed and shared with the Sponsor to provide feedback on marketing communications materials	I grant permission for the audio to be viewed and shared with the Sponsor to provide feedback on marketing communications materials yes	I grant permission for the audio to be viewed and shared with the Sponsor to provide feedback on marketing communications materials no
I understand that the audio may be used for educational, training, or informational purposes within the scope of optimizing marketing communications materials	I understand that the audio may be used for educational, training, or informational purposes within the scope of optimizing marketing communications materials yes	I understand that the audio may be used for educational, training, or informational purposes within the scope of optimizing marketing communications materials no
I understand that I can revoke this consent at any time by providing written notice. However, I acknowledge that revocation will not apply to recordings that have already been shared or distributed	I understand that I can revoke this consent at any time by providing written notice. However, I acknowledge that revocation will not apply to recordings that have already been shared or distributed yes	I understand that I can revoke this consent at any time by providing written notice. However, I acknowledge that revocation will not apply to recordings that have already been shared or distributed no
I am giving permission for the audio recording to be used as described above	I am giving permission for the audio recording to be used as described above yes	I am giving permission for the audio recording to be used as described above no

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* 4. We are required to pass on to the pharmaceutical company sponsoring this study details of adverse events, which are side effects and/or other safety information—hereinafter referred to as safety information—that may be mentioned during this study. Although what you say will be treated in confidence, if you mention safety information during the study, we will need to report it even if you have already reported it to the company or regulatory authorities.

In relation to reporting safety information, we need to know if you are willing to waive the confidentiality given to you under the Market Research Codes of Conduct. In the event that you waive confidentiality in relation to safety information reporting, any personal data provided during the reporting will be processed as follows:

a) Any personal data in relation to the safety information reported will be forwarded to the project sponsor; and

b) The project sponsor will record and retain any safety information, including personal data related to safety information, in the sponsor’s global database for as long as required, and in the interests of patient safety and in compliance with all applicable global laws and regulations; and

c) During the reporting of safety information, the project sponsor will not disclose such personal data to any un-associated third parties, with the exception of any disclosures required by applicable law, regulation, or the order of a competent authority.

Do you agree to waive the confidentiality given to you under the Market Research Codes of Conduct in relation to any safety information you report to us? If you agree, your contact details will be forwarded to the sponsor’s Safety Department for the express and sole purpose of follow-up of such report(s). Details of safety information may be reported to regulatory authorities along with your personal data. All other information provided by you in this study will remain confidential. If you prefer to preserve the confidentiality of this information, please select “I do not agree. If you do so, you can still participate in this survey.

I agree - If you provide your email address during the reporting of safety information, this will not be linked to your responses given during the interview.

I do not agree - If we become aware of safety information, we are obliged to report this to the pharmaceutical company. We will file this report without giving any of your details.

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* 5. Are you willing to participate in the interview on this basis?

Yes