Health
This questionnaire is a pre-screener to seek eligibility for a market research project. You do NOT get compensated for filling out this form. If you pre-qualify, you will receive a text or email from a Recruiter to call our office.  

Online Webcam Group via Desktop/Laptop with Webcam (NO CHROMEBOOK/TABLETS/PHONES)

Thursday, November 3, 2022

Times Currently Available: MUST join 15-mins early (3-hr commitment)

11am-1:45pm ET / 10am-12:45pm CT / 8am-10:45am PT

2pm-4:45pm ET / 1pm-3:45pm CT / 11am-1:45pm PT

Compensation: $75-$150 Pre-Paid Visa (if chosen) to be sent 8-10 weeks after full participation.

  • This is a 2-part session.  You must be available for the full 2 hours and 45 minutes, although you may be released after the first hour
  • Log in 15 minutes before the start time in case of any technical issues
  • Part 1: Everyone will participate in Part 1: 1 hour Online Survey, Incentive $75, if chosen.
  • There will be a 10-15 minute break where we ask you to wait patiently while the selection is made for part 2
  • Part 2: Some will be selected to continue to Part 2: 90 minute Webcam Focus Group, for an additional Incentive of $75, if chosen.
  • If you are selected for part 2, you will receive and email and a phone call alerting you that you have been selected. You will use QualBoard Video Chat to connect for the webcam focus group. 

Times are for reference only, booked by available quotas.
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Email *
First Name * *
Last Name *
Your Age * *
Your Age * *
What is your date of Birth? * *
MM
/
DD
/
YYYY
Gender * *
Ethnicity/Race * *
Required
Email * (if you have a Gmail account please enter that email address, preferred) *
Best Number to Text * *
Cell Phone Carrier * *
Alternate Number
Advanced Opinions communicates via text may we text to communicate with you? * *
Advanced Opinions communicates via email may we email you to communicate with you? * *
State *
The County you Live in (i.e., Lehigh) * *
The Make/Model of your Cell Phone * *
Are you currently * *
If you are a Student, are you
Clear selection
What is the highest level of education you have completed? * *
If you are currently working, please briefly describe your employment. (IF UNEMPLOYED/HOMEMAKER/RETIRED ENTER PREVIOUS) * If not applicable, enter N/A *
What is your job title? (IF UNEMPLOYED/HOMEMAKER/RETIRED ENTER PREVIOUS) * If not applicable, enter N/A *
What is the name of the company/organization you work for? (IF UNEMPLOYED/HOMEMAKER/RETIRED ENTER PREVIOUS) * If not applicable, enter N/A *
If you are currently working, what industry do you work in? (IF UNEMPLOYED/HOMEMAKER/RETIRED ENTER PREVIOUS) *  If not applicable, enter N/A *
(IF MARRIED OR CO-HABITATING) What is your spouse or partner’s current occupation? What Industry are they currently working in? (IF UNEMPLOYED/HOMEMAKER/RETIRED ENTER PREVIOUS) *Example: FT/Bus Driver/Transportation (If not applicable, enter N/A) *
What was your total household income before taxes during the past 12 months? (By this we mean all income brought into the home by all household members) * *
Which of the following best represents your current marital status? * *
Are you a parent/legal guardian.... *
If yes, how old are they? * *
Required

2. Do you or any member of your household or family, have previously or currently work …?

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Required

4. Which, if any, of the following has your doctor ever told you that you have? 

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Required

5. TT Q1.  How open are you, in general, to receiving vaccinations for any condition? 

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Not at all open
Extremely open


6. TT Q2. Using the scale below, indicate your level of agreement with the following statements.

5 – Strongly agree

4 – Somewhat agree

3 – Neither agree nor disagree

2 – Somewhat disagree

1 – Strongly disagree 

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1
2
3
4
5
I am usually the first among my friends & family to try something new.
I generally prefer to challenge the status quo.
I have a strong sense of purpose.
I often worry about my health worsening.
I often seek out information on new treatments on my own.
I feel positive about aging.
I proactively research vaccines my family needs.
My friends and family think getting vaccines is important.

7. TT Q3. Please rate your trust in pharmaceutical manufacturers overall.

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Do not trust at all
Completely trust

8a. Which of the following types of medical insurance do you currently have? 

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8b. Does your current health insurance provide vaccination coverage? 

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12a. When was the last time you, yourself, participated in any type of market research project, such as a discussion group or an individual interview? 

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12b. What was the subject of each study in the past 3 months?  
If none SKIP this question.
If chosen, Different people sometimes respond in different ways to the same product, and some side effects may not be discovered until many people have used a product over a period. For this reason, we are required by law to pass on to our client details of any side effects or product technical complaints related to their own products that are mentioned during the course of market research. Although what you say will, of course, be treated in confidence, should you mention during the discussion a side effect or product technical complaint when you, or someone you know, became ill after taking one of our client’s products, or a problem you have had with one of our client’s products we will need to report this, so that they can learn more about the safety of their products. Are you happy to participate in the interview on this basis? *

To participate in this study, you will need access to a working computer with reliable high-speed internet, with either Desktop Google Chrome or Mozilla Firefox web browsers. Do you have a computer with internet access and either web browser available for this project?  

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Do you have a working webcam?  

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For this research, the interview will be video recorded for analysis purposes, and we may also have colleagues and clients observing in the backroom or remotely. Do you agree for our colleagues and clients to listen to the interview under these conditions?

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You are sharing the personal information gathered about you, the opinions you shared and, if applicable, any video/photos taken during the research with Ipsos for the purpose of market research and analysis for this research only. Are you okay with sharing your information with Ipsos? 

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Adherence to market research codes of conduct

I understand that this survey is sponsored by a pharmaceutical company and is being carried out within the Market Research codes of conduct  I understand that the aim of this survey is to gain my views for market research purposes only and is not intended to be promotional. I agree that anything I see or read during this survey should be treated as confidential.  .  Information presented during the course of this survey is done to explore reactions to such information and should be assumed to be hypothetical rather than factual.  This study and the information presented are not to be used to influence your opinion or decision making on the survey topic. I understand that my identity will be kept confidential and none of my details will be passed on to the pharmaceutical company or any 3rd party, unless legally compelled to do so. I understand that the outputs of this survey will be used for information only by the pharmaceutical company.   I understand that any information I disclose will be treated in the strictest confidence and the results of the survey aggregated to provide an overall picture of attitudes to the areas being covered in this survey.  No answers will be attributable to me as an individual.   I understand that I have the right to withdraw from the survey at any time and to withhold information as I see fit and to refuse to be viewed or audio or video recorded. I acknowledge that the market research company will ask to speak to me in private to collect more information if during the survey I mention a specific product quality issue or an adverse event related to a product that is marketed by the pharmaceutical company ---even if I have already reported it to the company or regulatory authorities.   A quality issue or adverse event report will be provided to the pharmaceutical company.   I understand that my personal information will only be provided to the pharmaceutical company if I provide my consent.  The information within this report will only be used by the pharmaceutical company to satisfy its internal or regulatory requirements relating to the quality or safety of its product.   I understand that this survey will be either audio or video recorded for analysis and quality control purposes. I understand that in addition to the market research company, the pharmaceutical company or its agent may viewing the survey either in person or remotely for analysis purposes. I understand that if any individual viewing the survey should recognize me, the individual must withdraw from viewing unless I give my explicit permission for them to remain. I understand that the pharmaceutical company commissioning the survey may only use the recording for its internal decision making regarding the survey topic.


Can you please confirm that you understand and accept the points that I have just read out and are happy to proceed with the market research survey on this basis?


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Health Conditions Study Privacy Policy


Client has commissioned Ipsos-Insight, LLC, commonly known as “Ipsos”, to carry out this research survey on its behalf.  Ipsos-Insight, LLC is a specialist research agency registered in the Delaware and part of the Ipsos worldwide group of research companies. Ipsos’ full company details are: Ipsos-Insight, LLC, 200 Park Avenue, 11th Floor, New York, NY 10166.  This privacy policy explains how we use any personal data we collect from you when you participate in this Survey. You can find further information about Ipsos on its website that can be found here: https://www.ipsos.com.

Ipsos abides by all generally accepted professional industry standards and practices applicable to the advertising and marketing research industry including, without limitation, Insights Association, as such Ipsos abides by the Insights Association Code of Standards and Ethics and the International Code of Marketing and Social Research Practice issued by the ICC and ESOMAR, and other market research associated regulations and guidelines.

The categories of personal data we may collect about you through your involvement in the Survey include: 

Identification Data - your name, age, date of birth & gender Contact Data - your phone number, and email address, time zone Data relating to your financial and economic situation - annual household income Work Life Data - e.g. your profession and/or professional background, education Photos and Videos Special Categories of Personal Data or Sensitive Personal Data (we will only collect this with your prior explicit consent) - your ethnicity, data concerning health, current medications  Verbatims


Participation in this Survey is voluntary, and you are free to withdraw your consent at any time, either by not completing this Survey or later by contacting us as described under the paragraph entitled “Who to Contact…”.  

This privacy policy applies to this research survey (the “Survey”).

Topics:

What information will Ipsos collect about you?

How will Ipsos use the information you provide?

Who will have access to your information?

Will this survey collect information from children?

How long will Ipsos keep the information you provide?

How does Ipsos ensure your personal data is held securely?

Does this survey use Cookies or similar code?

How can you get access to your personal data, correct it, request its transfer and/or erasure?

Who to Contact if you have any questions about this Survey, Privacy Policy or your Personal Data?

Changes to this Privacy Policy?

Useful links


What information will Ipsos collect about you?

The categories of personal data we may collect about you through your involvement in the Survey include: 

Identification Data - your name, age, date of birth & gender Contact Data - your phone number, and email address, providence, time zone Data relating to your financial and economic situation - annual household income Work Life Data - e.g. your profession and/or professional background, education Electronic Connection Data - e.g. details about your computer, IP address, logs (See Paragraph 4 and 5) Photos and Videos Special Categories of Personal Data or Sensitive Personal Data (we will only collect this with your prior explicit consent) - your ethnicity, data concerning health, current medications  Verbatims 

If you do take part in this Survey, Ipsos will collect the personal data you provide when you complete the on-line questionnaire. Client has also asked Ipsos to provide recorded video and audio from the qualitative portion of this study.

In some instances, concerning our research, we may ask you to provide certain sensitive personal data, for example revealing your racial or ethnic origin, political opinions, religious or philosophical beliefs, trade-union membership or data concerning health or sex life. You do not have to answer these questions and such questions will always include a "prefer not to answer" option. Responses to these questions will remain confidential unless you explicitly and freely consent to your responses to these questions, together with your personal data, being passed to Client for further in-depth research analysis.

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How will Ipsos use the information you provide?

All the information you provide will be stored separately from the personal data used to invite you to participate in this research. Your participation in this research, together with your individual responses to the questions will be kept strictly confidential by Ipsos.

Your responses to this survey will be used solely for research analysis purposes only. The results of this research will be anonymous, statistical information only, and we can assure you that you will NOT be identifiable in any published results.  If you contact Ipsos for any reason regarding this research, your contact details will be used solely for the purpose of responding to your request.

We can assure you that any information you provide during this research will NOT be used for marketing, nor will we sell or pass on your information to any third party.

If you have any questions about this research or how your information will be used, please contact us as set forth in the paragraph entitled “Who to Contact…” below.  

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Who will have access to your information?

Access to your information will be limited to only those Ipsos staff involved in this research project, or who need access to support the systems used for this research, such as the online survey and research data analysis systems.  This may include staff in:

Other Ipsos Group companies involved in this research. Our sub-contractors who may carry out some of the processing on Ipsos’ behalf, and under Ipsos’ control; including the service providers who host or provide technical support for our systems.  

Some of the above may be based outside North America; however, they are required to abide by the same data privacy legal requirements and security arrangements as ourselves and will be subject to appropriate safeguards, a description of which can be obtained by contacting us as set out in the section headed “Who to contact if you have any questions about this study or this privacy policy?”.

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Will this survey collect information from children?

For research involving children, we will always seek consent of from a parent, legal guardian or other person legally responsible for the child before inviting them to take part in the research. However, we are only inviting adults to participate in this research survey.

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How long will Ipsos keep the information you provide?

How long we may retain personal data about you will depend upon the purposes for which the personal data was collected, whether you have requested the deletion of your personal data, and whether any legal obligations require the retention of your personal data (for example, tax and accounting purposes). We generally will not retain personal data any longer than is necessary to fulfil the purpose(s), which the personal data was collected and will be no more than twelve (12) months after the completion of the Survey project.   

This Survey project is scheduled to be completed on October 2022, at which point, we will securely delete all the personal data, leaving only anonymous research results as provided above.  Ipsos will also securely destroy the personal data that the above mentioned client provided for this research at this time.

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How does Ipsos ensure your personal data is held securely?

We take our responsibilities to keep your personal data secure very seriously. As such we take every reasonable precaution to ensure your information is protected from loss, theft or misuse. These precautions include appropriate physical security of our offices, controlled access to computer systems, and use of secure, encrypted internet connections when collecting personal data. As we collect personal data, we have implemented a personal data protection system that takes into account all the controls included in the legal requirements.

As part of our commitment to the security of your information, Ipsos has regular internal and external audits of its information security and is also certified to be compliant with the requirements of the International Standards for Information Security ISO 27001, Market, Opinion and Social Research ISO 20252, and Quality Management ISO 9001.

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Does this survey use Cookies or similar code?

Some on-line surveys collect information through the use of 'cookies'. These are small files stored on your computer. These files are used as sparingly as possible and only for quality control, validation and, more importantly, to prevent us sending you reminders for an on-line survey you have already completed. Specifically, in respect of cookies, further details of what cookies are can be found by visiting www.aboutcookies.org. These are small files stored on your computer and it is possible for you to delete 'cookies' or to prevent their use by adjusting the browser settings on your computer. However, if you do prevent our online survey from using cookies, our surveys and website will not work properly and you may not be able to participate in this Survey.

We also automatically capture information about your operating system, display settings and browser type in order to ensure that the survey questionnaire is delivered in a form suited to the software your computer is using.  If you participate in the Community using a mobile device (e.g. tablet or smartphone), we also capture the type and brand (e.g. iPhone).  We do not capture any other information from your computer, nor do we track or collect information outside of your participation in the Survey.  We do not link this automatically-collected data to any other information that we collect about users.

By participating and taking part in this online Survey, you agree to our use of cookies and similar technologies (“Cookies”) and the collection of information from your PC/Laptop or other computing device you may use whilst taking part in our online research activities as outlined below.

Essential Cookies

The essential cookies used in connection with this Survey are as follows: 


Site/Domain/Host


Cookie Name


Purpose of cookie


Domain name: https://www.focusgroup.com/


efs-<ID>-session


This cookie captures the participant’s session ID. A session ID is a unique number that a Web site's server assigns a specific user for the duration of that user's visit (session).


efs-<ID>-session-cookiePolicy


This cookie requires panelists to give their consent to the website to store or retrieve any information on a computer, smartphone or tablet. It is an additional cookie that requires panelists to agree to our cookie policy, that only has a timestamp in it.


csite


This cookie contains the activated country version of the survey as an abbreviation (used by GeoIP). This saves the language ID of the survey website the participant has visited. Based on the ID saved here, the participant is redirected to the corresponding website language version.


panel-session


This saves the survey session of the participant.


Imperium


RVIDExtId


These cookies are used to store the unique codes produced using digital fingerprinting. This is used as part of our systems to uniquely identify online survey participants and for essential quality control purposes. Please see the "Digital Fingerprinting" information below for more information.


RIDC


RIDSCR


$supplier-$panelist


BCSI-CS-3c406c8752813e90


RIDFPF


RID2


ISIStest

Convenience Cookies

These cookies provide information regarding site usage and site preferences, providing you with a better user experience. You will be prompted to accept the usage of these cookies from your browser when entering the site. These cookies are not essential for survey participation.


Site/Domain/Host


Cookie Name


Purpose of cookie


Other Suppliers' Domain


Suppliers own cookies


These pixels are inserted on registration form, usually on the conversion rate point, when suppliers are payed. It’s a double check for the suppliers and their partners on the number of respondents recruited. The code can be written in php/asp or javascript but not all the pixels use cookies (some supplier might, others will not). We don't know which suppliers do or do not use cookies.

Special Cookies

In addition to our use of cookies, our online surveys automatically capture information about your IP Address, operating system, screen display settings, browser type, use of Flash and Java and to detect whether your computer has a webcam. We use this information to:

ensure that the survey is delivered in a form suited to the software your computer is using. assist in providing support to you, should you have difficulty accessing or completing a survey. anonymized information is also used for research purposes, for example to determine the percentage of our Panelists in a specific country who use a certain type of browser.

The survey website is not designed to respond to “do not track” signals received from browsers. 

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Use of Digital Fingerprinting?

We may use digital fingerprint technology, also known as "Machine Identification" or “digital fingerprint”, to gather certain information about your computer hardware and software, for example, IP address, monitor display settings, type of browser used, the operating system of your computer, etc. This information is sent to our trusted provider who converts it into a unique serial number – the digital "fingerprint" – and determines if it matches previous fingerprints. The data collected in this process and the digital fingerprint created is not tied to any of your personal data but is stored separately on secured servers and only used for our legitimate interests of quality control, fraud prevention, preventing members from completing any survey more than once and for other online research quality purposes.

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How can you get access to your personal data, correct it, request its transfer and/or erasure?

You are entitled, at any time, to ask us the following:


to provide you access to your personal information


Each user has the right to know the purposes of the processing, our personal data categories, the parties or categories of parties with which your personal data is shared, the data retention period, and the source of our data that is not collected directly from you.


request the rectification of incorrectly entered data


We want to make sure that your personal information is correct and up-to-date. You can ask us to correct or remove information deemed inaccurate or obsolete.


to withdraw your consent


When your personal data is processed based on your consent, you can withdraw this consent at any given time and we shall comply accordingly.


request the deletion of your personal data


You can ask us to stop the processing or even delete the personal information that we hold about you. If your personal information is required to fulfill an Ipsos contractual obligation to you, Ipsos may be unable to fulfill this contractual obligation. Also, if your personal information is necessary for Ipsos to comply with certain legal obligations, your application can not be managed.


to object to the way we handle your data


Please note that you have the right to oppose the processing of personal data based on a legal basis that Ipsos considers legitimate. This does not apply if a legal provision requires that the personal data are data to be processed.


request the transfer of your data to another data processor (the right to portability)


You have the right to request from us to transfer your personal to another data processor in an easily readable format that can be used in this purpose. 


to provide you with a copy of the personal information we have


You can contact us if you want a copy of some or all of the personal information, we store about you. 


The right to lodge a complaint 

with a supervisory authority



If you have any complaints, we will appreciate if you give us an opportunity to resolve any issue first, by contacting us as set out below. You are, however, always entitled to contact your regulatory authority regarding any complaint.

To exercise any of these rights, please contact our data privacy team, as set forth in the below paragraph titled “Who to Contact…”. 

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Who to Contact if you have any questions about this Survey, Privacy Policy or your Personal Data?

If you have any questions about this Survey or how your personal data will be used, please contact the study team.  They can be contacted by email sent to Johnny.Wang@ipsos.com with “Health Conditions Study, 22-074655-01” as the subject line.

Or by letter sent to “Health Conditions Study, 22-074655-01” Survey

Ipsos-Insight, LLC

200 Park Ave, FL 11 

New York, NY 10166

If you have any questions or require further information this privacy policy, Ipsos’ compliance with data protection laws or information we may hold about you, please contact our data protection team. You also have the right to request the correction of any personal data we hold about you. Furthermore, you have the right for all the information you have provided to us, to be transferred to another party. In various circumstances, you also have the right to request from us the deletion or erasure of the personal data we hold about you. For further details, please contact our data privacy team. They can be contacted by email sent to DPO.USA@ipsos.com with “Health Conditions Study, 22-074655-01” as the subject line.

Or by letter sent to: Ref: “Health Conditions Study, 22-074655-01”

Ipsos-Insight, LLC

Attn: US Data Privacy Officer

200 Park Ave, FL 11 

New York, NY 10166


Or by phone by calling: 1-833-931-1521 and referencing “Health Conditions Study, 22-074655-01”

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Changes to this privacy policy:

This privacy policy was last updated on November 1, 2020.

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Useful Links:

Ipsos Group: www.ipsos.com

Insights Association: www.InsightsAssociation.org

ESOMAR: www.esomar.org 

I have read, understood and accept the Privacy Policy (the “Privacy Policy”) and consent to the use of my personal data in accordance with the Privacy Policy in connection with this research study.

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Home Address *
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If chosen, PARTICIPATION INSTRUCTIONS: 
Must have high speed internet AND use a desktop/laptop computer with a webcam Cannot use a smartphone or tablet to participate Must use Google Chrome or Mozilla Firefox (Internet Explorer is not compatible) You will receive an email from QualBoard with the log in instructions the night before your group.  

Open this email and register with QualBoard asap to avoid any issues at the start of the session. This email will be resent the day of the session.  

This is a 2-part session.  You must be available for the full 2 hours and 45 minutes, although you may be released after the first hour Log in 10 minutes before the start time in case of any technical issues Part 1: Everyone will participate in Part 1: 1 hour Online Survey, Incentive $75 There will be a 10-15 minute break where we ask you to wait patiently while the selection is made for part 2 Part 2: Some will be selected to continue to Part 2: 90 minute Webcam Focus Group, for an additional Incentive of $75 If you are selected for part 2, you will receive and email and a phone call alerting you that you have been selected. You will use QualBoard Video Chat to connect for the webcam focus group.  Incentives will be sent by mail, in the form a Visa card within 8-10 weeks of the project date.   
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