Discussions on Eye Conditions

1.Please fill out the following contact information:

First Name

Last Name

City

State

ZIP/Postal Code

Email Address

Phone Number

2.LaGrippe Research is conducting this research on behalf of Motivo Insights. The purpose of this initial screening interview is to establish your interest in, and eligibility for, participation in this piece of market research. Please know that:

Motivo Insights is an independent market research company, presently working for a pharmaceutical company.
The research will involve participating in a web-assisted telephone interview lasting approximately 45 minutes
Any information, materials, or products you are shown have been created for market research purposes and should be treated only as hypothetical or as a prototype (example format) at this time. Motivo Insights has not had any part in creating any materials or products, and your honest opinions – whether positive or negative – are important.
In recognition of your time and contribution to this research, you will receive $125
You can withdraw from the research at any time, and have the right to withhold information
Your responses will be collated with those of other respondents and presented to the sponsor in aggregated or anonymous form; your identity will not be revealed. Your responses will be otherwise confidential and will not be used for any other purposes or disclosed to any third party without your approval.

Are you happy to proceed with this survey on this basis?

Yes

No

3.Motivo Insights will comply with all U.S. laws in protecting your personal data, and also in accordance with BHBIA guidelines and the (state as relevant) MRS/EphMRA, PBIRG and ABPI codes of conduct.

Are you happy to proceed with this survey on this basis?

Yes

No

4.Adverse Events / Product Complaints
We are required to pass on to our client details of adverse events/product complaints pertaining to their products that are mentioned during the course of market research. Although your responses will, of course, be treated in confidence, should you raise during the survey an adverse event or product complaint, we will need to report this even if it has already been reported by you directly to the company or the regulatory authorities. In such a situation you will be asked whether or not you are willing to waive the confidentiality given to you under the Market Research Codes of conduct specifically in relation to that adverse event/product complaint. Everything else you say during the course of the interview will continue to remain confidential, and you will still have the option to remain anonymous if you so wish.

Are you happy to proceed with this survey on this basis?

Yes

No

5.If during the survey, you disclose an adverse event or product complaint we will reach back out to you to ask you if you are willing to provide your name and date for the medical safety department to help them investigate the event/complaint more fully.

Do you agree to this? (You do not have to agree to this in order to participate in the research)

Yes

No

6.Have you ever been diagnosed by a healthcare professional with any of the following types of eye conditions?

Please select all that apply.(Required.)

Ocular surface disease (e.g., dry eye, blepharitis)

Inflammatory eye disease (e.g., uveitis, scleritis)

Cataract or lens-related disease

Corneal disease (e.g., keratoconus, corneal dystrophy)

Retinal vascular disease (e.g., retinal vein occlusion, hypertensive retinopathy)

Macular disease (e.g., wet age-related macular degeneration, diabetic macular edema)

Glaucoma or optic nerve disease

Other (please specify)

None of the above

Discussions on Eye Conditions - Patients

Screening Survey