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* 1. Contact Info

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* 2. We are required to pass on to the pharmaceutical company sponsoring this study details of adverse events, which are side effects and/or other safety information—hereinafter referred to as safety information—that may be mentioned during this study. Although what you say will be treated in confidence, if you mention safety information during the study, we will need to report it even if you have already reported it to the company or regulatory authorities.

In relation to reporting safety information, we need to know if you are willing to waive the confidentiality given to you under the Market Research Codes of Conduct. In the event that you waive confidentiality in relation to safety information reporting, any personal data provided during the reporting will be processed as follows:

a) Any personal data in relation to the safety information reported will be forwarded to the project sponsor; and
b) The project sponsor will record and retain any safety information, including personal data related to safety information, in the sponsor’s global database for as long as required, and in the interests of patient safety and in compliance with all applicable global laws and regulations; and
c) During the reporting of safety information, the project sponsor will not disclose such personal data to any un-associated third parties, with the exception of any disclosures required by applicable law, regulation, or the order of a competent authority.
Do you agree to waive the confidentiality given to you under the Market Research Codes of Conduct in relation to any safety information you report to us? If you agree, your contact details will be forwarded to the sponsor’s Safety Department for the express and sole purpose of follow-up of such report(s). Details of safety information may be reported to regulatory authorities along with your personal data. All other information provided by you in this study will remain confidential. If you prefer to preserve the confidentiality of this information, please select “I do not agree. If you do so, you can still participate in this survey.

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* 3. [If Agree] If you provide your email address during the reporting of safety information, this will not be linked to your responses given during the interview.

[If Disagree] If we become aware of safety information, we are obliged to report this to the pharmaceutical company. We will file this report without giving any of your details.

Are you willing to participate in the interview on this basis?

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* 4. If you agree to this document, you give permission to our client and other authorized service providers assisting in the performance of this research for: understanding reactions and recommended optimizations to marketing communications.

The information that we may use includes all information gathered during this research. However, please only use your first name to ensure your identity is kept anonymous.

As a reminder, any information released and/or used by our client and the sponsor will never identify you directly. The sponsor may use interview recordings for non-promotional purposes to better understand certain medical conditions, treatments, and/or practices along with any other lawful use cases, including as related to safety-related issues.

All information obtained as a result of this study will be treated as confidential by our client and (where applicable) the sponsor and will be used only in accordance with the purposes specified in this consent. The sponsor will store any information obtained during this research for as long as required by applicable laws.

Your participation in this research is entirely voluntary, and your privacy is important to us. You also have the right to revoke this consent or exercise any right you have in respect to your personal information under applicable law by contacting us. At any time, you may discontinue your participation in the research survey. If you wish to revoke the information you have already provided when discontinuing your participation, you must state this intention clearly and we will promptly cease to use your information.

Are you willing to participate in the interview on this basis?

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