OMB#
0910-0695
Exp. 3/31/2024
Patient Interview Screener
[Display at bottom of Introduction screen] 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 3/31/2024. The time required to complete this information collection is estimated to average 5 minutes per response to answer the questions to determine eligibility. |
Biosimilars Patient Study
Introduction
Thank you for your interest in this study sponsored by the U.S. Food and Drug Administration. Please answer the following questions to see if you are eligible to participate in an online interview about health-related materials for a specific type of medicine.
The interview will be led by a researcher through an online video platform. If you’re eligible for the interview , you can participate from home using a computer and web camera. The discussion will last about 90 minutes. You will be emailed about your $75 honorarium within one business day after the interview concludes and have the option to choose between a physical or electronic gift card.
To determine your eligibility for this study, we need to ask you a few questions. These questions should take no more than 5 minutes.
What is your age?
Age 18 or older |
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CONTINUE |
Under 18 |
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TERMINATE |
Have you ever worked…? [Accept multiple responses.]
For a drug or pharmaceutical company |
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TERMINATE |
For a market research or marketing company, including RTI International or L&E Research |
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TERMINATE |
For the U.S. federal government (not including as a member of the military) |
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TERMINATE |
As a medical professional (such as a physician, nurse, or pharmacist) |
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TERMINATE |
None of the above |
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CONTINUE |
When was the last time you participated in an interview or a focus group for a research study?
Within the last 6 months |
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TERMINATE |
More than 6 months ago |
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CONTINUE |
Never |
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CONTINUE |
Don’t know |
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TERMINATE |
To participate in this study, you will need a desktop computer, laptop computer, or a tablet (not just a smartphone). Which type of device are you most likely to use if you participate in the study?
Desktop computer |
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CONTINUE |
Laptop computer |
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CONTINUE |
Tablet (e.g., iPad) |
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I don’t have any of the devices listed above |
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TERMINATE |
To participate in this study, you will also need a webcam (attached or built into the device) and high-speed Internet access. Can you meet these requirements?
Yes |
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CONTINUE |
No |
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TERMINATE |
Do you have any vision, hearing, or speaking issues that would prevent you from reviewing English-language written materials and videos during the interview?
Yes |
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No |
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CONTINUE |
Are you okay with being audio and video recorded during the interview?
Yes |
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CONTINUE |
No |
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TERMINATE |
Has a healthcare professional ever diagnosed you with any of the following medical conditions? [Accept multiple responses.]
Ankylosing spondylitis / Spondyloarthritis
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Ask Q9, then CONTINUE to Q14 |
Psoriatic arthritis
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Ask Q9, then CONTINUE to Q14 |
Rheumatoid arthritis
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Ask Q9, then CONTINUE to Q14 |
Cancer
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Ask Q9, then CONTINUE to Q10 |
Crohn’s disease
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Ask Q9, then CONTINUE to Q14 |
Ulcerative colitis
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Ask Q9, then CONTINUE to Q14 |
Eczema / Atopic dermatitis
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Ask Q9, then CONTINUE to Q14 |
Psoriasis
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Ask Q9, then CONTINUE to Q14 |
Type 1 diabetes
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Ask Q9, then CONTINUE to Q12 |
Type 2 diabetes
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Ask Q9, then CONTINUE to Q12 |
None of the above |
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SKIP to Q14 |
How long ago were you diagnosed with [condition]? [Ask for each condition selected by respondent] [Allow 1–99 years and 0-12 months]
___ years ___ months (if less than 1 year) |
Which type(s) of cancer were you diagnosed with? [Accept multiple responses]
Breast |
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CONTINUE |
Colorectal |
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CONTINUE |
Kidney |
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CONTINUE |
Leukemia |
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CONTINUE |
Lung |
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CONTINUE |
Lymphoma |
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CONTINUE |
Myeloma |
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CONTINUE |
Skin |
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CONTINUE |
Other (please specify) |
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Have you ever been diagnosed by a healthcare professional with neutropenia, a blood-related side effect of chemotherapy?
Yes |
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CONTINUE to Q14 |
No |
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CONTINUE to Q14 |
How long have you been using insulin to treat your diabetes?
More than one month |
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CONTINUE |
Less than one month |
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SKIP to Q14 |
Not currently taking insulin |
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SKIP to Q14 |
Do you take insulin at least once per day?
Yes |
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CONTINUE to Q14 |
No |
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CONTINUE to Q14 |
Are you the parent or guardian of a child who has been diagnosed with diabetes by a healthcare professional? If so, which type of diabetes?
Yes, type 1 diabetes |
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CONTINUE |
Yes, type 2 diabetes |
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CONTINUE |
No |
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SEE Q19 INSTRUCTIONS |
What is this child’s age?
Age 18 or older |
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TERMINATE IF Q8=None of the above |
Under 18 |
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CONTINUE |
How involved are you in managing your child’s diabetes (e.g., scheduling doctor’s appointments, making medication decisions, administering insulin)?
Extremely involved |
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CONTINUE |
Frequently involved |
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CONTINUE |
Somewhat involved |
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SEE Q19 INSTRUCTIONS |
Not at all involved |
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SEE Q19 INSTRUCTIONS |
How long has your child been using insulin to treat his or her diabetes?
More than one month |
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CONTINUE |
Less than one month |
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SEE Q19 INSTRUCTIONS |
Not currently taking insulin |
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SEE Q19 INSTRUCTIONS |
Does your child take insulin at least once per day?
Yes |
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SEE SKIP PATTERN BELOW |
No |
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SEE SKIP PATTERN BELOW |
[Skip pattern:
If individual’s responses have checked one or more of the yellow boxes, proceed to Q19.
If individual’s responses have checked only the green boxes, skip to Q21
If no yellow or green boxes selected, terminate and display closing script.]
These next questions ask about medicines that you take for your health condition(s). Have you ever taken one or more of the following medicines to treat [display condition(s) based on responses to Q8, Q10, and Q11]?
[Display list of medications only for applicable medical conditions in Q8, Q10, and Q11.]
[Allow multiple responses. If one or more medications selected, continue to Q20. If no medications selected, terminate.]
[RECRUIT AT LEAST 20% TAKING AT LEAST ONE BIOSIMILAR]
List of Medicines for Q19
Condition |
Medicines Brand Name [pronunciation] [generic Name] |
Ankylosing Spondylitis/ Spondyloarthritis |
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Psoriatic Arthritis |
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Rheumatoid Arthritis |
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Cancer (leukemia) |
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Cancer (blood – including lymphoma and myeloma) |
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Cancer (lung) |
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Cancer (skin—melanoma, squamous cell carcinoma, basal cell carcinoma) |
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Cancer (colorectal) |
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Cancer (breast) |
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Cancer (kidney) |
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Cancer (other types) |
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Neutropenia (from cancer treatment) |
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Crohn's Disease |
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Ulcerative Colitis |
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Eczema/Atopic Dermatitis |
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Psoriasis |
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Please fill in the following information about each medicine that you selected.
[Populate first two columns based on Q19 responses]
[If currently taking any medicine for more than one month, proceed to Q21]
[If not currently taking a medicine, but the medicine was taken within the last year and taken for more than one month, proceed to Q21]
Medicine |
Condition |
Are you still taking this medicine? |
YES |
How long have you been taking it? |
NO |
When did you last take this medicine? |
How long did you take this medicine when you were still using it? |
[Medicine] |
[Condition] |
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[Medicine] |
[Condition] |
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[Medicine] |
[Condition] |
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Would you be comfortable discussing this medicine/these medicines in an interview?
Yes |
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ELIGIBLE |
No |
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TERMINATE |
Demographic Questions
What is the highest level of education you have completed?
Less than high school diploma [Eligible for lower education groups]
High school graduate or GED [Eligible for lower education groups]
Some college
Technical or associates degree (2-year)
4-year degree
Graduate or professional degree [RECRUIT NO MORE THAN 14% OF SAMPLE]
Private insurance through an employer, group health plan, broker, agent, or Federal or state marketplace plan
Medicaid or Medicare [RECRUIT 30% OF TOTAL SAMPLE NON-PRIVATE]
Veterans Affairs, Tricare, or the Department of Defense [RECRUIT 30% OF TOTAL SAMPLE NON-PRIVATE]
Currently uninsured
Other [please specify]: _______________________
What is your race? You may select more than one. [Accept multiple responses]
White [RECRUIT NO MORE THAN 80% OF SAMPLE]
Black or African American
Asian
Native Hawaiian or Other Pacific Islander
American Indian or Alaska Native
Are you of Hispanic, Latino, or Spanish origin?
Yes [RECRUIT 15% OF SAMPLE]
No
In which state do you live? [Display drop down list. Recruit at least 20% in each Census region.]
[drop down list of states]
What was your total household income before taxes during the past 12 months? Your response will be kept private.
$30,001 to $65,000
$65,001 to $99,999
More than $100,000
Prefer not to answer
What is your sex?
Closing Scripts
Declined to Begin Screener
Thank you for your time.
Completed Screener
You have completed the online screener. One of our recruiters will be in touch if you qualify for this study. Thank you for your time.
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Alexander, Jennifer |
File Modified | 0000-00-00 |
File Created | 2022-07-01 |