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 Sam at (224) 360-3366 or email samantha@lagripperesearch.com.

Thank you!

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* 1. Please fill out the following contact information:

LaGrippe Research is interviewing people like yourself, on behalf of Lumanity for market research, that they are conducting on behalf of a sponsoring pharmaceutical company. We are currently conducting a market research study in which we will be interviewing a range of patients such as yourself in order to gather the voices of those living with Geographic Atrophy.

This is to help us develop a better understanding of the journey that you have been on and the events along the way such as whom you saw and what management approach has been provided. The aim of this market research is to gain your views and is not in any way promotional and promotional materials will not be viewed.

As part of the research, we will share with you a hypothetical profile of a treatment for Geographic Atrophy. This treatment may or may not become available in your country and would be provided on the advice of a qualified healthcare professional.

We realise that this can be a sensitive issue and would like to reassure you that the interviewers that we use are very experienced and highly trained in discussing emotional topics affecting health. If you want to withhold information that is no problem at all. You are also entitled to withdraw from the research at any time should you feel uncomfortable or no longer wish to take part.

Should you be eligible and want to participate, the research will take the form of:
  • 60-minute in-depth interview
As a token of our gratitude for your time, we would be pleased to offer you $100 upon completion of your interview.
Lumanity is an independent market research agency working within the local market research and pharmaceutical industry codes, and any regional and local laws and regulations.

The information you provide during this interview will be used for market research purposes only and any personal data (e.g., name, phone number, address) will be treated confidentially by Lumanity and any business partners assisting in the execution of this market research. No personal information will be released to the sponsor. Your responses to the market research questions will be released to the sponsor in a blinded format that does not identify you directly. Your responses will be combined with other respondents’ responses and presented to the sponsor in an aggregated and anonymous format.

Your personal information will be retained by Lumanity for 2 years and then deleted or anonymized.

Your personal information may be transferred to a third country beyond your country of residence which may have different applicable privacy laws. Lumanity and the sponsor company take appropriate safeguards to make sure that your personal information is protected. These include implementing special contract clauses, known as Standard Contractual Clauses; further details can be provided upon request.

This market research is not to change your opinion, promote or sell you anything. You will not be contacted for marketing purposes based on your participation in this interview.

You have the right to access, rectify and erase the information you provide. You have the right to receive a copy of the data you provide in a commonly used format or direct us to provide the data to a third-party of your choice. In certain circumstances, you may be entitled to restrict the processing Lumanity, or the sponsoring company performs, and to object to any further processing.

At any time, you may end this interview. You also have the right to withdraw this consent at any time without affecting the lawfulness of any processing based on consent before its withdrawal. Should you wish to revoke the information you provided prior to discontinuing, you must state this intention clearly and we will promptly cease to use your information. After this interview is complete, you may contact Lumanity to revoke your consent. You have the right to lodge a complaint with the supervisory authority in the jurisdiction where you live, work or where you believe your rights were violated if you have concerns.

For further information about how Lumanity protects your personal information and how you may exercise your data protection rights, you can contact Lumanity at the following contact details:
  • PRJ005843TeamGAPatientJourneyandPreferenceStudy@lumanity.com
  • +44(0)2076089300
Please also see the relevant Privacy Notice of Lumanity, available at:
  • https://lumanity.com/privacy-policy/
In order to participate in this interview, you must give your permission for Lumanity to use the information collected during this interview including your personal data. If at any point, the purposes of this market research and use of the responses you provide change, we will contact you to explain the new purposes and ask for your consent.

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* 2. The interview will be audio and/or video and/or live streamed and with your consent, the sponsor of this research would like to listen to and/or view these recordings either live or after the interview has completed. Clients who may listen/view in this way will be based in the EU and/or outside the EU.

Are you happy for our clients to listen to and/or view the interview live via live streaming?

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* 3. Are you happy for our client to be sent the audio/video OR audio and video recordings?

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* 4. We need your consent in order for us to collect and use any information about you. We won’t keep any personal data you give us longer than 2 years for market research analysis.

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* 5. With your permission, we would like to transfer the data outside of the EEA/UK (and transferred to the USA, where the client is based). We will make sure that it is kept secure at all times.

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* 6. Do you consent to participate in this interview?

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* 7. Any side effects and/or product complaints that may arise during the course of this market research interview must be reported to the commissioning company to help them learn more about the safety of their medicines. If this happens, we will notify the pharmacovigilance department at the commissioning company who in turn may need to contact you for further information. This will have no impact on the confidentiality and anonymity associated with the interview itself. Do you consent to the interview on this basis?

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