*1.Contact Info(Required.)

Name

Phone

E-Mail

State

Gender

Age

*2.In the event that you mention a side effect (referred to as safety information) of a medication or device, we are required to pass the details of what happened to the safety department at the pharmaceutical company sponsoring the research and the FDA.

In those situations, where you mention safety information, we need to know if you are willing to waive the confidentiality given to you under the Market Research Codes of Conduct, because we will need to collect personal data

a) Personal data (e.g. name, address, email, phone number) 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.(Required.)

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.

*3.This consent is designed to gain your permission to audio/video record for the purposes of market research. The video will collect faces and voices that are not altered but will ensure that no other identifying information, such as your full name, location details, contact information, or specific background details, are present. By signing this form, you agree to the following terms for you/your child:

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

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

ð I acknowledge that the audio/video will be shared with the Sponsor in a manner that does not reveal additional identifying information beyond my first name, face, and potentially voice.
ð I understand that my full name and contact details will remain confidential and will not be shared in connection with the audio/video for purposes of understanding their condition and the market

Distribution:
ð I grant permission for the audio/video to be viewed and shared with the Sponsor for market research.

ð I understand that the audio/video may be used for educational, training, or informational purposes within the scope of the market research .(Required.)

I consent (to be audio/video recorded/for my child to audio/video recorded) for the purposes of market research. I understand that the video will retain my face and voice will not be altered

I do not consent and do not want to do the interview

*4.Are you willing to proceed with this interview?(Required.)

Yes

No

*5.Are you or any member of your immediate family currently employed by a pharmaceutical company, a government regulatory agency, or as a consultant to any pharmaceutical companies or market research, advertising, or public relations agencies?(Required.)

Yes

No

*6.Which of the following best describes your gender identity?(Required.)

Male

Female

Non-binary/other

Self Descriibe