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$100 Study - Sexual Health
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1.
Contact Info
(Required.)
Name
Phone
E-Mail
Age
State
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2.
Different people sometimes respond in different ways to the same medicine, and some side effects may not be found until many people have used a medicine over a period. If you mention a side effect related to a medicine made by the sponsor of the study in your survey responses, we must pass that information on to the sponsor so that they can learn more about the safety of their own medicines. You can choose to include your name and contact information in the report of those specific side effects, or if you wish, you may be anonymous in the report. For everything else you include in your survey, your name will continue to be anonymous.
Do you agree to this?
(Required.)
1. Yes, and I consent to including my name and contact information in the report
2. Yes, but wish to remain anonymous
3. No
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3.
Which best reflects your current gender?
(Required.)
1. Male
2. Female
3. Transgender man
4. Transgender woman
5. Non-Binary
Other (please specify)
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4.
What sex were you assigned at your birth?
(Required.)
Male
Female
Other (please specify)
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5.
Which of the following best describes your race or ethnicity?
Select all that apply.
(Required.)
1. White/Caucasian
2. Hispanic/Latino
3. African American/Black
4. Asian/Pacific Islander
5. Native American
6. Other
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6.
Please indicate if you, or any member of your household, work for any of the following? Select all that apply.
(Required.)
1. For an advertising agency or public relations firm with clients in the pharmaceutical industry
2. For a market research firm or the market research department of a company
3. For marketing firm or the marketing department of a company related to pharmaceutical products
4. Centers for Disease Control and Prevention
5. For a company that is involved in the manufacturing, distribution or sales of medications, pharmaceuticals, medical products or medical equipment
6. For an online health or medical service provider
7. Healthcare profession or in a doctor’s office, pharmacy, clinic or hospital
8. Kaiser Permanente
9. The US Federal Government or any state or local government
10. For a communication or news organization
99. None of the above
