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1 forms found in the DOM

Name: hubin-form — POST /hubin/1f00136a6bc00e898e7b42c8c680ec41/

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          <br><em><em><strong>Please note:</strong> Compensation will only be paid to the above person and you may only participate in this survey once.</em></em>
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                <option value="ZWE">Zimbabwe</option>
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            </div>
          </div>
        </div>
        <p>Thank you for your interest in this survey. Please complete your details here, review the contents of this page carefully and then click the <em>"Agree to terms and start survey"</em> button at the bottom right of this page.</p>
        <p><em><strong>Please note:</strong> Compensation will only be paid to the above person and you may only participate in this survey once.</em></p>
      </div>
      <div class="ld-content-box checkmark-p">
        <h1>Your rights:</h1>
        <p>Your participation is voluntary.</p>
        <p>You may withdraw from the survey at any time and choose not to answer any further questions.</p>
        <p>We will protect your identity and your responses will only be reported anonymously except as laid out in our <a href="https://www.m-panels.com/privacy">Privacy Policy</a>.</p>
      </div>
      <div class="ld-content-box checkmark-p">
        <h1>You agree to:</h1>
        <p>Read each question thoroughly, carefully think about your responses and provide only honest answers. (Please note; Survey compensation may not be paid if you fail to do so.)</p>
        <p>Allow us to report details of any <a href="##adv" class="js-adverse-events-link">adverse events</a> and product complaints pertaining to our clients products to them. You will separately be asked if you are willing to waive your
          confidentiality in this regard.</p>
        <p>m-panels <a href="https://www.m-panels.com/compensation-provisions" target="_blank">Compensation Terms</a> or
          <a href="https://www.m-panels.com/terms" target="_blank">Terms of Use</a><!-- or <a href="https://www.m3globalresearch.com/research/screening.cfm?lang=149" target="_blank">Screening Guidelines</a>-->.</p>
        <p>m-panels collecting and processing your personal data for the purposes of de-duplication, fraud control and as otherwise provided in our <a href="https://www.m-panels.com/privacy" target="_blank">Privacy Policy</a>.</p>
      </div>
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      <div class="m3-logo"><img src="/images/m-panels-logo-m360research.png" width="100%" alt="m-panels"></div>
      <div class="ld-study-details">
        <h1>About This Survey:</h1>
        <div class="entity entity-study-details">
          <div class="name">Study Details:</div>
          <div class="value">
            <div class="loi">5<small> minutes</small></div>
            <div class="details">Online </div>
          </div>
        </div>
        <div class="entity">
          <div class="value">Quick 5-minute study</div>
        </div>
        <div class="entity entity-top entity-compensation">
          <div class="name">Compensation Offered:</div>
          <div class="value">15 USD</div>
        </div>
        <div class="entity entity-topic">
          <div class="name">Topic:</div>
          <div class="value">Coverage with Evidence Development (CED)</div>
        </div>
        <div class="entity entity-deadline">
          <span class="name">Deadline:</span>
          <span class="value">Thursday, July 6, 2023</span>
          <em>or earlier if we achieve our targets before then</em>
        </div>
        <div class="entity entity-ref">
          <div class="name">m-panels Reference:</div>
          <div class="value">R61261-804</div>
        </div>
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        <small>AGREE TO TERMS AND</small><br>
        <big>START SURVEY</big>
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          <div></div>
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          <div></div>
        </div>
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    <div class="s-modal hide" id="js-adverse-events-dialog">
      <p>m-panels and our client research agencies are required to pass on to the sponsoring pharmaceutical company, details of adverse events related to their product(s) that are raised during the course of market research interviews.</p>
      <p>Although this is an online market research interview and how you respond will, of course, be treated in confidence, should you raise an adverse event or product complaint in a specific patient or group of patients, the agency will need to
        report this, even if it has already been reported by you directly to the company or the regulatory authorities.</p>
      <p>If you decide to disclose your personal details in association with any adverse event or product complaint report, this information will be disclosed to the commissioning company. In such a situation you may be contacted specifically in
        relation to that adverse event. Everything else you contribute during the course of the interview will continue to remain confidential.</p>
      <p>You will be asked separately whether or not you are willing to waive the confidentiality given to you under market research codes of conduct specifically in relation to any adverse event or product complaint reported.</p>
      <div class="btn close-button js-close">Close</div>
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Text Content

WELCOME !

Thank you for your interest in this survey. Please review the contents of this
page carefully and then click the "Agree to terms and start survey" button at
the bottom right of this page.


Please note: Compensation will only be paid to the above person and you may only
participate in this survey once.


WELCOME:

First Name:
Last Name:
First Line of Home Address:
Zip Code/Postal Code:
Country: United States of America France Germany Italy Portugal Spain United
Kingdom Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola
Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia
Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize
Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia-Herzegovina
Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin
Islands Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada
Cape Verde Cayman Islands Central African Republic Central America and Caribbean
Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo
Congo, Democratic Republic of the Cook Islands Costa Rica Côte d'Ivoire Croatia
Cuba Curaçao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic
Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland
Islands (Malvinas) Faroe Islands Fiji Finland French Guiana French Polynesia
French Southern Territories Gabon Gambia Georgia Ghana Gibraltar Greece
Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana
Haiti Heard Island and Mcdonald Islands Holy See (Vatican City State) Honduras
Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel
Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's
Republic of Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya
Liechtenstein Lithuania Luxembourg Macao, Special Administrative Region of China
Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands
Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco
Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal
Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk
Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian
Territory, Occupied Panama Papua New Guinea Paraguay Peru Philippines Pitcairn
Poland Puerto Rico Qatar Réunion Romania Russia Rwanda Saint-Barthélemy Saint
Helena Saint Kitts and Nevis Saint Lucia Saint-Martin (French part) Saint Pierre
and Miquelon Saint Vincent and Grenadines Samoa San Marino Sao Tome and Principe
Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten
(Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South
Georgia and the South Sandwich Islands South Korea South Sudan Sri Lanka Sudan
Suriname Svalbard and Jan Mayen Islands Swaziland Sweden Switzerland Syria
Taiwan Tajikstan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and
Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda
Ukraine United Arab Emirates United States Minor Outlying Islands Uruguay U.S.
Virgin Islands Uzbekistan Vanuatu Venezuela Vietnam Wallis and Futuna Islands
Western Sahara Yemen Zambia Zimbabwe

Thank you for your interest in this survey. Please complete your details here,
review the contents of this page carefully and then click the "Agree to terms
and start survey" button at the bottom right of this page.

Please note: Compensation will only be paid to the above person and you may only
participate in this survey once.


YOUR RIGHTS:

Your participation is voluntary.

You may withdraw from the survey at any time and choose not to answer any
further questions.

We will protect your identity and your responses will only be reported
anonymously except as laid out in our Privacy Policy.


YOU AGREE TO:

Read each question thoroughly, carefully think about your responses and provide
only honest answers. (Please note; Survey compensation may not be paid if you
fail to do so.)

Allow us to report details of any adverse events and product complaints
pertaining to our clients products to them. You will separately be asked if you
are willing to waive your confidentiality in this regard.

m-panels Compensation Terms or Terms of Use.

m-panels collecting and processing your personal data for the purposes of
de-duplication, fraud control and as otherwise provided in our Privacy Policy.


ABOUT THIS SURVEY:

Study Details:
5 minutes
Online
Quick 5-minute study
Compensation Offered:
15 USD
Topic:
Coverage with Evidence Development (CED)
Deadline: Thursday, July 6, 2023 or earlier if we achieve our targets before
then
m-panels Reference:
R61261-804
AGREE TO TERMS AND
START SURVEY


m-panels and our client research agencies are required to pass on to the
sponsoring pharmaceutical company, details of adverse events related to their
product(s) that are raised during the course of market research interviews.

Although this is an online market research interview and how you respond will,
of course, be treated in confidence, should you raise an adverse event or
product complaint in a specific patient or group of patients, the agency will
need to report this, even if it has already been reported by you directly to the
company or the regulatory authorities.

If you decide to disclose your personal details in association with any adverse
event or product complaint report, this information will be disclosed to the
commissioning company. In such a situation you may be contacted specifically in
relation to that adverse event. Everything else you contribute during the course
of the interview will continue to remain confidential.

You will be asked separately whether or not you are willing to waive the
confidentiality given to you under market research codes of conduct specifically
in relation to any adverse event or product complaint reported.

Close