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 Alex at 847-533-4052 or email alex@lagripperesearch.com.

Thank you!

Question Title

1. Please fill out the following contact information:

Question Title

2. Before we start, we would like to assure you that we act in accordance with the ESOMAR, EphMRA, and PBIRG/ Insights Association codes of conduct regarding anonymity and confidentiality. This research is sponsored by a pharmaceutical company and the aim of this study is to gain your views for market research purposes only and is not in any way promotional. The company who is commissioning this research does not hold or see any information regarding respondents.

With the exception of the note below regarding the recording and reporting of adverse events, other additional safety information, and/or product quality complaints, any information you disclose will be treated in the strictest confidence and the results are anonymized so no answers are attributable to any individuals.

By entering the survey link/consenting to continue you understand and agree to the following:
  • I understand that the information I provide is for market research purposes only.
  • I agree to keep confidential and not use for myself or disclose to anyone else any of the content of this survey.
  • I understand that my name will not be associated with my responses.
  • I understand that I have the right to refuse to answer questions or withdraw at any time.

Before beginning the survey/screener, please be aware that by law, we are required to pass on to our client details of adverse events, other additional safety information and/or product quality complaints that pertain to their products and are mentioned during the course of market research interviews and surveys. Although this is an on-line market research questionnaire/screener and how you respond will, of course, be treated in confidence, should you raise an adverse event, other additional safety information and/or product quality complaint in a specific patient or group of patients, we will need to report this even if it has already been reported by you directly to the company or to the regulatory authorities.

You will be asked whether you consent to us passing your details to the client company’s drug safety department for their follow-up, but you may choose to remain anonymous. This will have no impact on the confidentiality and anonymity associated with the interview itself.

Do you consent to proceed with the interview on this basis? (Required.)

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