Screener - Patient Advocacy Organization

OMB Control No: 0910-0697

Expiration Date: 12/31/2023

Paperwork Reduction Act Statement: 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 0910-0697. The time required to complete this information collection is estimated to average 90 minutes per response, including the time for completing the screen questions, testing the focus group link, logging onto the online platform, reviewing instructions, searching existing data sources, gathering, and maintaining the data needed, and completing and reviewing the collection of information.

Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing burden to [email protected].

The study we are conducting is on behalf of the U.S. Food and Drug Administration (FDA).

Patient and Caregiver Diversity in FDA Patient Engagement Activities

Patient Advocacy Organization

Q1 What is your age?

• 18-35 

• 36-55

• 56-65  

• 75+ 

Q2 Do you work for a food allergy patient advocacy organization? 

• Yes (1)

• No (2)

Q3 What is the name of food allergy organization that you work for?

____________________________________

Q4 What is your position or title at the organization?

____________________________________

Q5 Where is the food allergy organization located?

______________________________________________________________

Q6 What is your email address?

_______________________________________________________________

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