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1. Please complete the contact information below.

2. Please supply us with a secondary contact number.

Murray Hill Center standard policy requires at least two contact numbers for each respondent.

If the secondary number you give us is not your own number but a friend, family member or co-worker please indicate as such.

3. What is your gender?

4. What is your current age?

5. What is your ethnicity?

6. What is your current work status?

7. What is your Occupation-Job Title, Company you work for, and Industry?

(If you are Retired, Unemployed or a Homemaker Please tell us your previous employment information. If you are a full-time student please enter your Grade, School and Major)

8. 8. What is the highest level of education that you have completed?

9. 9. What is your current marital status?

10. . Are you or is anyone in your immediate family currently employed by a pharmaceutical company, healthcare company, and marketing or marketing research company?

11. With which of the following conditions, if any, have you been diagnosed by a doctor?

        (Diagnosed here means that a physician has confirmed that you suffer from the condition)

12. There are many different types of epilepsy. Which type of epilepsy or seizure disorder have you been diagnosed with?

13. How long have you been diagnosed with Epilepsy and how long have you been diagnosed with partial onset seizure disorder (also known as focal seizure disorder)

14. . What prescription medications (medications that must be obtained with a physician’s prescription) are you aware of for the treatment of Partial Onset Seizure disorder also known as focal seizure disorders associated with epilepsy?  If you cannot think of any, please type “none.”

 Please list as many as you can think of.

15. Which of the following medications have you ever taken and which do you currently take for the treatment of Partial Onset Seizure disorder also known as focal seizure disorders associated with epilepsy?

16. You previously indicated that you are currently taking for your Partial Onset Seizure disorder also known as focal seizure disorders associated with epilepsy. For how long have you been taking each medication?

17. How active do you consider yourself to be in researching your epilepsy/ seizure disorder diagnosis and/or treatment options?

        Please use a scale of 1 to 7 where “1” represents very inactive in researching the diagnosis and treatment options, and “7” represents very active in researching the diagnosis and treatment options.

18. Overall, how satisfied are you with your current medication for your partial onset seizures (also known as focal seizure disorder) associated with epilepsy?

 

 Please use a scale of 1 to 7 where “1” represents very dissatisfied with symptom control of your current medication, and “7” represents very satisfied with symptom control of your current medication

19. Do you have daily access to a computer with high-speed internet?

20. Again, using a scale of 1 – 10, where 1 is not at all comfortable and 10 is extremely comfortable; please tell me how comfortable you are with each of the following:

21. Do you have daily access to a computer with high speed internet?

22. If you qualify you log on at your convenience from home for about 60 minutes per day (for 3/4 days), to respond to and build on the day’s discussion.  New questions will appear daily by 3:00 PM (EST). You will be provided with a pseudonym name so that you can feel free to comment honestly and openly.  Your comments will not be attributed to you.

Prior to the start of the online session, we will email you with instructions and provide you with the study link and your password.  You will be contacted on the day before the VRT starts to confirm receipt of your instruction email. Are you will to participate fully?

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