$150 + $25 HW Opinion Study

Question Title

* 1. This consent is designed to gain your permission to audio/video record for the purposes of obtaining feedback on marketing communications materials. 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:

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

	yes	no
I consent to be audio/video recorded for the purposes of optimizing marketing communications material	I consent to be audio/video recorded for the purposes of optimizing marketing communications material yes	I consent to be audio/video recorded for the purposes of optimizing marketing communications material no
I understand that the video will retain my face and my voice will not be altered	I understand that the video will retain my face and my voice will not be altered yes	I understand that the video will retain my face and my voice will not be altered no
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.	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. yes	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. no
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 CONTINUE	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 CONTINUE yes	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 CONTINUE no
I grant permission for the audio/video to be viewed and shared with the Sponsor for providing feedback on marketing communications materials CONTINUE	I grant permission for the audio/video to be viewed and shared with the Sponsor for providing feedback on marketing communications materials CONTINUE yes	I grant permission for the audio/video to be viewed and shared with the Sponsor for providing feedback on marketing communications materials CONTINUE no
I understand that the audio/video may be used for educational, training, or informational purposes within the scope of optimizing marketing communications materials	I understand that the audio/video may be used for educational, training, or informational purposes within the scope of optimizing marketing communications materials yes	I understand that the audio/video 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 videos 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 videos 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 videos that have already been shared or distributed. no
I am giving permission for the audio/video recording to be used as described above	I am giving permission for the audio/video recording to be used as described above yes	I am giving permission for the audio/video recording to be used as described above no

Question Title

* 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 pharmaceutical company sponsoring the research and the FDA.

Although what you say will be treated in confidence, in alignment with the Market Research Codes of Conduct, if you mention safety information during the study, we will need to report it even if you have already reported it to your doctor, the company or regulatory authorities.

a) 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.

Are you willing to proceed with this survey/interview?

Yes

No

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* 3. Contact Info

Name

Phone

E-Mail

State

Age

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* 4. 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?

Yes

No

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* 5. Which of the following best describes your gender identity?

Male

Female

Transgender

Non-binary/other

Prefer to self-describe