Rapid Message Testing with Consumer Panel - Medication Guide Template for Buprenorphine Products (CDER)

OMB Control No. 0910-0695

Expiration date: 2/28/2021

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0910-0695 and the expiration date is 2/28/2021. The time required to complete this information collection is estimated to average 3 minutes per response, including the time for reviewing instructions and completing and reviewing the collection of information.

FDA RAPID – MESSAGE #21

“BTOD Medication Guide”

Recruiting Screener

Introduction

The U.S. Food and Drug Administration, or FDA, hired Westat to help them get opinions about health information. EurekaFacts is helping Westat and FDA find people who may be interested in being interviewed about health information. To make sure you are a good fit for the interview, please take about 3 minutes to answer the questions below.

1. What is your age?

1. Under 18  INELIGIBLE

2. 18 to 29

3. 30 to 39

4. 40 to 49

5. 50 to 59

6. 60 or older

2. Do you, or does any member of your household or immediate family work…?

1. For a market research company  INELIGIBLE

2. For an advertising agency or public relations firm  INELIGIBLE

3. In the media (TV, radio, newspapers, magazines)  INELIGIBLE

4. As a healthcare professional (doctor, nurse, pharmacist, medical assistant, dietician, etc.)  INELIGIBLE

5. In the pharmaceutical industry  INELIGIBLE

6. None of the above  GO TO Q3

3. [Ask if drawn from sublingual buprenorphine panel] In the past 12 months, have you used any of the following buprenorphine products that are applied under the tongue or inside the cheek for the treatment of opioid use disorder? Select all that apply.

1. BUNAVAIL® (buprenorphine and naloxone) film

2. CASSIPA® (buprenorphine and naloxone) film

3. SUBOXONE® (buprenorphine and naloxone) film

4. SUBOXONE® (buprenorphine and naloxone) tablet

5. SUBUTEX® (buprenorphine) tablet

6. ZUBSOLV® (buprenorphine and naloxone) tablet

7. A generic version of a buprenorphine and naloxone film or tablet

8. None of the above  INELIGIBLE

9. Don’t know  INELIGIBLE

4. What is your sex?

1. Female

2. Male

5. What is the highest grade or level of education you have completed?

1. Less than High School

2. High School Diploma or GED

3. Some College, including Associate’s Degree

4. Bachelor’s Degree (for example: BA, BS)

5. Graduate or Professional Degree

6. Are you of Hispanic, Latino, or Spanish origin?

YES

NO

7. What is your race? Please select one or more.

White

Black or African-American

American Indian or Alaska Native

Asian

Native Hawaiian or other Pacific Islander

8. What state do you live in? [DROP DOWN LIST OF US STATES, INCLUDING “OUTSIDE OF THE US”] [“OUTSIDE OF THE US”  INELIGIBLE]

Request for Contact Information

C1. Thank you for answering these questions. Based on your answers, you may be selected for an interview. If selected and you finish it, you will get $35. At the start of the interview, the interviewer will ask if it’s okay to audio record it. This helps Westat to make sure they hear everything you say correctly. If you are chosen for an interview, you will get [a packet in the mail/an email] for this study. Make sure to have [the packet with you/access to your email] during the interview. Is it okay with you for EurekaFacts to share your contact information with Westat?

YES

NO  INELIGIBLE

Thank and Terminate

Thank you for taking our survey. Unfortunately, based on your responses, you are not eligible for this study. However, we appreciate you taking the time to answer our questions today.

Contact Information

C2. In the space below, please give us the best information to contact you by phone, email, and regular mail. Please know that Westat will not share your information with anyone else. Your personal information will be deleted upon completion of the research project.

Contact Information

Name ______________________________________________________________________

Address 1 ___________________________________________________________________

Address 2 ___________________________________________________________________

City, State, ZIP _______________________________________________________________

Phone Number _______________________________________________________________

Email Address________________________________________________________________

Technology Preferences

C3. The Westat interviewer would like to be able to show you information on her computer screen during the interview. Westat will send directions for how to do this. Which app do you prefer for screen sharing? [SINGLE SELECT]

1. Skype

2. Google Hangouts

3. WebEx

4. I am not able to use any of these, please just call me

Closing

Thank you for your answers to these questions. If you are chosen for an interview, someone from Westat will contact you with the next 1-2 days.