Biosimilars Prescribing Survey

Data to Support Drug Product Communications

Screening Questions

Biosimilars Prescribing Survey

OMB: 0910-0695

Document [docx]
Download: docx | pdf

OMB Control # 0910-0695

Expiration Date: 02-28-2021


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 time required to complete this information collection from eligibility to completion of the survey is estimated to average 23 minutes per response, including the time for 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 PRAStaff@fda.hhs.gov.


Department of Health and Human Services (HHS)/ Food and Drug Administration (FDA) Biosimilars Survey


Programmer Notes


Participants should not be able to go back in the survey, only forward.


Unless otherwise indicated, only one question should appear per screen.


Require an answer to all screener questions. Prompt for an answer to all other questions: “Are you sure you don’t want to provide a response?”



INTRODUCTION


The U.S. Department of Health and Human Services and the Food and Drug Administration are sponsoring this survey. We are interested in gathering information about the way you think about and use names of prescription drug products. The survey should take you approximately 23 minutes to answer. Please complete these initial screening questions to see if you qualify.


SCREENER


S1. What is your age? [Numeric field] [If younger than 18, terminate. Do not allow ages over 90.]


Value

Label

-99

Refused [Terminate]

Shape1





S2. What is your gender? [Single punch]


Value

Label

01

Male

02

Female

-99

Refused [Terminate]


S3. Do you have a medical degree? [Single punch]


Value

Label

01

Yes, I have an M.D. [Skip to S5]

02

Yes, I have a D.O. [Skip to S5]

03

No [Continue to S4]

S4. Are you a licensed nurse practitioner or physician’s assistant? [Single punch]


Value

Label

01

Yes, I am a nurse practitioner

02

Yes, I am a physician’s assistant

03

No [Terminate]

-98

Valid skip

-99

Refused [Terminate]


S5. Which best describes your primary medical specialty? [Single punch]


Value

Label

01

Rheumatology

02

Oncology

03

Hematology

04

Dermatology

05

Nephrology

06

Gastroenterology

07

Other [Terminate]

-99

Refused [Terminate]


S6. For how many years have you been practicing in your medical profession? [Numeric field] [Do not allow numbers >65]


Value

Label

-99

Refused [Terminate]

Shape2





S7. Are you currently practicing? [Single punch]


Value

Label

00

No [Terminate]

01

Yes

-99

Refused [Terminate]



S8. What is your place of practice? [Single punch]


Value

Label

01

Teaching hospital

02

Hospital

03

Medical school

04

Clinic or infusion center

05

Private practice

06

Other (specify)

-99

Refused


S9. In what state is your primary practice? [Dropdown (50 states and District of Columbia)]


Value

Label

-99

Refused


S10. Which of the following best describes your race/ethnicity? Mark all that apply. [Multi punch]


Value

Label

-99

Refused


S10A. American Indian or Alaska Native

S10B. Asian

S10C. Black or African American

S10D. Native Hawaiian or Other Pacific Islander

S10E. White

S10F. Prefer to not answer


Value

Label

00

Not selected

01

Selected


Do you identify as Hispanic or Latino? Yes/no


S11. Within the last five years, have you or an immediate family member worked for any of the following types of businesses? [Single punch]

  • An advertising or public relations firm

  • A marketing or market research firm or department

  • A marketing or market research consultant

  • Any kind of media company, like a TV or radio station or newspaper

  • A pharmaceutical company


Value

Label

00

No

01

Yes [Terminate]


S12. When, if ever, was the last time you participated in a marketing research study, such as a consumer interview or a group discussion? [Single punch]


Value

Label

01

Within the past three months [Terminate]

02

Over three months ago

03

Never



[DISPLAY IF ELIGIBLE]

You are eligible to participate in the current study. Please click the button below to read through our consent form and continue to the survey.


[CLOSING FOR INELIGIBLE PARTICIPANTS]

I’m sorry, but you are not eligible for this study. There are many possible reasons why people are not eligible. These reasons were decided earlier by the researchers. However, thank you for your interest in this study and for taking the time to answer our questions today.


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorTaylor, Kellie
File Modified0000-00-00
File Created2021-01-15

© 2024 OMB.report | Privacy Policy