Screening Survey

Thank you for your interest in our upcoming study. Please fill out the following preliminary questions below. Once completed, we will follow up with you shortly after regarding your eligibility in the project and if qualified, to discuss details and scheduling. If you do not qualify, we will email you at the end of the project thanking you for your time and asking if you would be interested in future projects that you may qualify for.

If you have any questions, please contact Maggie at 847-373-4104 or email maggie@lagripperesearch.com.

Thank you!

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* 1. Please fill out the following contact information:

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* 2. LaGrippe Research is conducting this survey on behalf of Branding Science (BSc), an independent market research agency. We are conducting market research on behalf of a pharmaceutical company, and they would really value your opinion.

The purpose of the research is to understand the experiences of people living with geographic atrophy and it will take the form of a 60-minute interview. We will provide a payment of $125 paid by bank transfer following the successful completion of the interview.

Taking this opportunity to have your voice heard would greatly help us further our understanding and your participation is greatly appreciated. If you have any questions, please contact Maggie at LaGrippe Research by email: maggie@lagripperesearch.com or call this number: 847-373-4104.

Please advise this named person if for any reason you are unable to attend the research; by arriving more than 15 minutes after the start time, you agree it may not be possible to participate in the research.

Please note: Everything you see or discuss during the research session is confidential and should not be disclosed to anyone after the research day.

PRIVACY
The research will comply with your local Data Protection Laws and Market Research Society’s Code of Conduct including BHBIA, ESOMAR, EphMRA, Insights Association and all other relevant national codes of practice.

You will remain anonymous unless you give permission to be identified.

You have the right to refuse to answer questions or to withdraw at any time.

Any information you provide us with will be treated as confidential, it will be combined with feedback from others like yourself. The aim of this market research is to gain your views and is not intended to be promotional and no one will try to sell you anything. Your information will only be used for this purpose and will not be passed on to any third party without your permission.

You can find a full copy of Branding Science’s privacy notice online; this explains all of your data protection rights and is available at http://www.branding-science.com/privacy/. An electronic copy in PDF format is also available upon request.

DISCLOSURE OF ADVERSE EVENT REPORTING
Different patients sometimes respond in different ways to the same medicine, and some side effects may not be discovered until many people have used a medicine over a period of time. We are required to pass on to the commissioning healthcare / pharmaceutical company any details of side effects or product complaints relating to their products that are mentioned during the interview. This is to help them learn more about the safety of their medicines/devices. If this happens, we will need to collect details and report the side effects or product complaint. You will be asked if you give permission for us to pass your contact details to the company’s drug safety department for them to follow up. This will have no impact on the confidentiality and anonymity associated with the interview itself.

Side effect or product complaint follow-up activities will not be extended to any other data gathering activity. You still have the option to remain anonymous if you so wish.

Can we continue with the interview on this basis?

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* 3. OBSERVATION AND RECORDING
The discussion will be:
  1. Video / Audio-recorded for analysis at a later stage. This is for the use of BSc and the recruitment agency only. The recording may be analysed by staff of BSc who are operating outside the European Economic Area (“EEA”), or the country where the interview takes place.
  2. Listened and watched live as it happens by people from the client company at their offices in the US, Germany, China, and Japan.
  3. Audio-recorded but listened at a later date by people from the client company at their offices in US, Germany, China, and Japan. Access to the recording will only be available to specific personnel via a password protected link. It will not be shared with anyone else or used for any other purpose without your permission.
  4. Audio clips from your interview may be used as part of a deliverable for the commissioning company, but only for internal use. This is to help them to understand the market research better.
Branding Science and commissioning company staff may be based outside the country where the interview takes place. All staff have confirmed their agreement to follow Observer Guidelines. Adequate data protection measures will be put in place to comply with the Data Protection Laws of the country in which the interview took place. No personal information (such as your name or contact details) will be shared and everything you say during the interview will not be traced back to you.

The screening process to verify whether you qualify or not for this market research study will involve asking you questions about your medical conditions and making decision based on your answers.

Is this acceptable to you?

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* 4. RECONTACT
We may want to further explore your responses to some of the questions answered. Would you be prepared to be re-contacted by LaGrippe Research within 3 months?

Are you happy to proceed with this screening interview on this basis?

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* 5. For the 60-minute interview, you will need to have a desktop/laptop computer to join our zoom meeting (No tablets or smartphones) - are you able to proceed?

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* 6. Are you, or is any member of your household employed by:
  • A marketing research or consulting firm or the marketing department of any company OR
  • A pharmaceutical or biotechnology company OR
  • A manufacturer, distributor, or wholesaler of pharmaceuticals or medicinal products OR
  • A manufacturer, distributor, or wholesaler of non-prescription drugs or pharmaceutical products?

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* 7. Have you / someone you care for received a diagnosis of geographic atrophy from an eye specialist (e.g. ophthalmologist or retinal specialist)? Geographic atrophy is an advanced form of a condition called dry age-related macular degeneration (dry type of AMD or a more advanced, atrophic form of AMD).

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