*1.Contact Info(Required.)

Name

Phone

E-Mail

State

Gender

Age

*2.This study is being conducted on behalf of a sponsoring global biopharmaceutical company (“Sponsor”).

You can withdraw from the study at any time and withhold information as you see fit. Should you decide to withdraw from the study, however, we reserve the right to withhold all or a portion of the payment that would otherwise be made for your participation.

All interviews are audio and video recorded and research colleagues and/or the Sponsor may be viewing or listening to the interview and/or may review the recording at another time. This interview is also being livestreamed via a secure internet connection to research colleagues and/or the Sponsor who are viewing remotely.

The study that you will be participating in is being conducted as double-blind. This means that neither you nor the Sponsor will be told each other’s identity.

We are required to pass on to the Sponsor details of adverse events, other pharmacovigilance data (also known as PV data), and/or product technical complaints pertaining to their products that are mentioned during the market research study.

"Adverse Event" or “AE” refers to any untoward medical occurrence in a patient who takes or uses a product, and which does not necessarily have a causal relationship with that product. An adverse event can therefore be any unfavourable and unintended sign (including an abnormal laboratory finding, for example), symptom, or disease, temporally associated with the use of such a product, whether or not considered related to that product.

“Pharmacovigilance Data” or “PV Data” includes any adverse event (serious or not), any incident (serious or not), or any of the following special situations (with or without adverse events): any report of misuse; any medication error; any off-label use (intentional use outside the labelled indication); any overdose (intentional or not); any drug abuse, dependence, addiction, (withdrawal syndrome); any lack of efficacy; any drug exposure during pregnancy or child exposure during breastfeeding or conception (whether from the male or female); any occupational exposure (unintentional exposure during work); accidental exposure; unexpected therapeutic benefit; any suspected transmission of infectious agents; and/or suspected drug interactions involving active ingredients or their metabolites.

“Product complaint”, “Product Technical Complaint” or “PTC” refers to any written, electronic, or oral communication that alleges deficiencies related to the identity, quality, durability, reliability, safety, efficacy or performance of a product, device, its packaging, or any written leaflet or other information provided with such product or device, after it is released for distribution.

Should you mention during the discussion an adverse event or other PV Data or product technical complaint regarding yourself or a specific patient about a specific product, we will need to report this even if it has already been reported by you directly to the company or to regulatory authorities.

In such a situation, you will be asked whether you are willing to waive the anonymity given to you under the ICC/ESOMAR International Code on Market and Social Research practice and the EphMRA Code of

Conduct specifically in relation to that adverse event/product technical complaint. If you are willing to waive your anonymity, your name and contact information will be provided to the research Sponsor, who may report it to the U.S. Food and Drug Administration, and you may be contacted for follow-up questions regarding the adverse event, other PV Data, and/or product technical complaint. If you are not willing to waive your anonymity, the adverse event, other PV Data, and/or product technical complaint will be reported anonymously. Regardless, everything else you say during the study will continue to remain anonym(Required.)

Yes

No

*3.Are you, or is any member of your household, affiliated with or employed by any pharmaceutical companies as a consultant and/or researcher (other than participating in clinical trials)?(Required.)

Yes

No

*4.Are you currently employed by any of the following (excluding research honoraria, consultancy, speaking engagements, and advisory board participation)? Select all that apply.(Required.)

Pharmaceutical manufacturer or contract research organization (CRO)

Medical equipment manufacturer

Market research or advertising firm

Regulatory agency (e.g., FDA, EMA)

Government agency

None of the above

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

Male

Female

Transgender

Non-binary

Self Descriibe

*6.What is your ethnicity? Select all that apply(Required.)

Hispanic or Latino

White

Black or African American

Asian

American Indian or Alaska Native

Native American or Other Pacific Islander

Prefer to self-identify, specify: