*1.Contact Info(Required.)

Name

Phone

E-Mail

Gender

Age

State

*2.The research will be audio recorded for analysis purposes. Do you agree to this?(Required.)

Yes

No

*3.If you mention any adverse events during our conversation (e.g., undesirable change of health, side effects during treatment, lack of effectiveness, etc.), we’ll ask for your consent to disclose personal data to the pharmaceutical company and provide you with an address to report your adverse event directly. The pharmaceutical company will only use your personal data to comply with its own legal obligations. In any event, we are obligated to transfer any adverse events you bring up to pharmaceutical company on an anonymous basis if you choose not to provide your consent.

Are you willing to proceed with this screening interview on this basis?(Required.)

Yes

No