Screener- Patient Caregiver

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 Caregiver

Q1. What is your age?

• 18-35 

• 36-55

• 56-65  

• 75+ 

Q2. What is your email address?

Q3. What is your relation to food allergy (select ALL that apply)?

• I have food allergy

• Caregiver to CHILD or CHILDREN with food allergy

Age(s) of child or children (fill in) _______

• Caregiver to SPOUSE with food allergy

Age of SPOUSE (fill in) _______

• Caregiver to PARENT person with food allergy

Age of PARENT (fill in) _______

• Caregiver to OTHER person with food allergy

Age of OTHER PERSON (fill in) _______

• No, neither me nor a person in my care has a food allergy. (End survey)

Q4. How did you, or a person in your care, know that you/they have a food allergy?

• A doctor told me/them I/they have food allergy.

• I/they experienced allergic reaction symptoms that made me/them believe I/they have food allergy.

• Both

• Not applicable

Q5. What is your ethnic background? (Select all that apply)

• Hispanic or Latino origin

• Not of Hispanic or Latino origin

• please fill in: ____________

• Prefer not to answer

Q6. What is your racial background? (Select all that apply)

• American Indian or Alaskan Native

• Asian

• Native Hawaiian or Other Pacific Islander

• Black or African American

• White

• please fill in: ______________

• Prefer not to answer

Q7. How would you describe your gender?

• Male

• Female

• please fill in: _______

• Prefer not to say

Q8. What is your highest level of education?

• Less than high school

• High school graduate/GED

• Trade or technical school

• Some college education

• College graduate

• Postgraduate education

Q9. What is your City and State of residency?

________________________________________________________________

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