First Name
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Last Name
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Email
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Date of birth
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Phone number
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What is your gender?
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Female Male Gender diverse
In what country do you live?
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United Kingdom United States of America Other
Please select your country:
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Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cabo Verde Cambodia Cameroon Canada Central African Republic Chad Chile China Colombia Comoros Congo Costa Rica Côte d'Ivoire Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Fiji Finland France Gabon Gambia Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Holy See Honduras Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria North Korea North Macedonia Norway Oman Pakistan Palau Palestine State Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Korea South Sudan Spain Sri Lanka Sudan Suriname Sweden Switzerland Syria Tajikistan Tanzania Thailand Timor-Leste Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates Uruguay Uzbekistan Vanuatu Venezuela Vietnam Yemen Zambia Zimbabwe
In what part of United Kingdom do you reside in?
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England Northern Ireland Scotland Wales
In what part of England do you reside in?
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Bedfordshire Berkshire Bristol Buckinghamshire Cambridgeshire Cheshire City of London Cornwall Cumbria Derbyshire Devon Dorset Durham East Riding of Yorkshire East Sussex Essex Gloucestershire Greater London Greater Manchester Hampshire Herefordshire Hertfordshire Isle of Wight Kent Lancashire Leicestershire Lincolnshire Merseyside Norfolk North Yorkshire Northamptonshire Northumberland Nottinghamshire Oxfordshire Rutland Shropshire Somerset South Yorkshire Staffordshire Suffolk Surrey Tyne and Wear Warwickshire West Midlands West Sussex West Yorkshire Wiltshire Worcestershire
In what part of Scotland do you reside in?
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Aberdeenshire Angus Argyll and Bute City of Aberdeen City of Dundee City of Edinburgh City of Glasgow Clackmannanshire Dumfries & Galloway East Ayrshire East Dunbartonshire East Lothian East Renfrewshire Falkirk Fife Highland Inverclyde Midlothian Moray Na h-Eileanan Siar (Western Isles) North Ayrshire North Lanarkshire Orkney Islands Perth and Kinross Renfrewshire Scottish Borders Shetland Islands South Ayrshire South Lanarkshire Stirling West Dunbartonshire West Lothian
In what part of Wales do you reside in?
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Baenau Gwent Brigend (Pen-y-bont ar Ogwr) Caerphilly (Caerffili) Cardiff (Caerdydd) Carmathenshire (Sir Gaefyrddin) Ceredigion Conwy Denbighshire (Sir Ddinbych) Flintshire (Sir y Fflint) Gwynedd Isles of Anglesey (Ynes Môn) Merthyr Tydfil (Merthyr Tudful) Monmouthshire (Sir Fynwy) Neath Port Talbot (Castell-nedd Port Talbot) Newport (Casnewydd) Pembrokeshire (Sir Benfro) Powys Rhondda Cynon Taff Swansea (Abertawe) Torfaen (Tor-faen) Valeof Glamorgan (Bro Morgannwg) Wrexham (Wrecsam)
In what part of Northern Ireland do you reside in?
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Antrim Armagh Down Fermanagh Londonderry Tyrone
In what part of United States do you reside in?
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Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming
In what city do you live in?
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Zip Code/Post Code
What is your current job status?
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Freelance Full time employed Full time employed-Business owner Part time employed Part time employed-Business owner Retired Self employed Student Unemployed
What is your current job title?
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What is your job title tier?
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Account Management Actor Admin Assistant Administrator Apprentice Assistant Childcare Consultant C-Suite (COO, CFO, CEO, etc.) Customer Service Director Financial Freelancer Healthcare HR HR Director Individual Contractor Intern IT Junior Manager Office Manager Other/None of the above Senior Manager Specialist Supervisor Teacher Technician Trainee
In what industry do you work in?
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Agriculture Automotive Aviation Banking, accountancy, insurance and other financial services Beauty/Cosmetics Business, consulting and management Charity and voluntary work Construction Creative arts and design Culture Education Energy and utilities Engineering and manufacturing Environment Food and drink Government, public services and administration Healthcare Hospitality and events management Information technology (IT) and computer services Law Law enforcement and security Leisure and sport Marketing, advertising and PR Media and entertainment Other/None of the above Professional business services Real Estate Recruitment and HR Retail Sales Science and pharmaceuticals Social care Technology Telecommunication Tourism Transport and logistics
What is your total annual household income (after tax)?
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Below 30,000 30,000 - 50,000 50,000 - 70,000 70,000 - 100,000 Above 100,000
What is your highest completed education level?
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Associate degree Bachelor's degree Doctorate (PhD) High school diploma or GED Master's degree Professional degree Some college
What is your marital/relationship status?
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Cohabiting Divorced Living with housemate(s) Living with parents Married Single Widowed
Do you have children?
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Yes No
How many children do you have?
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1 2 3 4 5 More than 5
What best describes your ethnicity?
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African African American Any other Black/African/Caribbean background Any other Mixed/Multiple ethnic background Any other white background Arab Asian Bangladeshi Black British Caribbean Chinese Gypsy or Irish Traveller Hispanic/Latino Indian Mixed White and Asian Mixed White and Black African Mixed White and Black Caribbean Pakistani White American White British White European White Irish Other - Please specify
Specify your ethnicity:
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Adverse event / safety data
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We are required to pass on to the pharmaceutical company sponsoring the study details of adverse events and/or other safety information - hereinafter referred to as safety information - that are mentioned during this study. Although what you say will be treated in confidence, should 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.
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In relation to reporting safety information situations 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:
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Any personal data in relation to the safety information reported will be forwarded to the project sponsor; and The project sponsor will record any safety information, including personal data received in the sponsor’s global database, in the interests of patient safety and in compliance with all applicable global laws and regulations;
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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.
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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.
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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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Please confirm your age:
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If you are human, leave this field blank.
