Thank you for your interest in our upcoming study. Please fill out the following preliminary questions below. Once completed, if you qualify, we will follow up with you shortly after to discuss details and scheduling. If you do not qualify, we will email you at the end of the project thanking you for your time and asking if you would be interested in future projects that you may qualify for.

If you have any questions, please contact Maggie at 847-373-4104 or email maggie@lagripperesearch.com

Thank you!

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* 1. Please fill out the following contact information:

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* 2. During this questionnaire, we will ask you to provide personal health information, including information about your medical conditions and the management of these conditions. You may elect to withhold any information that you are not comfortable providing.

We want to assure you that your responses will be kept completely confidential and anonymous and will be analyzed in aggregate. Your survey responses will never be linked with your name or any identifying information. This research is in full compliance with the Health Information Portability and Accountability Act (HIPAA) and related guidelines set forth by the Council of American Survey Research Organizations (CASRO).

Do you still agree to continue?

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* 3. By consenting to continue, you understand and agree to the following:
  • I understand that the information I supply is for market research purposes only.
  • I agree to keep it confidential and not use it for myself or show to anyone else any of the content of this survey.
  • I understand that my name will not be associated with my responses.
  • I understand that I have the right to refuse to answer questions or withdraw at any time.
Thank you for agreeing to participate in this questionnaire. Please make every effort to be open and honest when responding to questions. The data from the survey will be “blinded” which means your name will not be associated with any of your answers. All answers from all of the respondents will be pooled and reported together; please note responses will be transmitted and stored securely. No identifying information will be collected in this survey and all respondents will remain anonymous. We will ensure that the strictest standards of privacy are maintained. We appreciate and thank you for your candid responses to all of the following questions.

ADVERSE EVENTS:
We are required to pass on to our client details of adverse events that are mentioned during the course of market research. Although what you say will, of course, be treated in confidence, should you raise during the discussion an adverse event that has happened to you or another patient, we will need to report this even if it has already been reported.

Adverse experience information provided is shared with regulatory agencies, the sponsoring company's affiliates worldwide, and business partners with whom the sponsoring company has contractual agreements. Any information that identifies you or another patient directly, such as initials or date of birth, will be handled confidentially. Everything else you say during the course of the interview will continue to remain confidential. A Drug Safety representative of the sponsoring company may reach out to you for additional details to learn about the adverse events, if necessary.

Do you still agree to continue?

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* 4. RECORDING AND OBSERVATION:
All interviews will be audio/video recorded and transcribed for analysis and quality control purposes. The study sponsor, or its agents, may also listen to the recording for internal decision making about the study topic. All personally identifiable information will be redacted.

If selected for the research, you will be provided with a form explaining how the sponsoring company intends to use the recording/transcripts. You will be asked to sign that form which supplies permission for that usage. Supplying your permission is optional, you can decide not to sign.

Would you be interested in taking part under these circumstances?

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* 5. Do you agree to the interview being recorded and shared with the sponsoring company for these purposes?

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* 6. Please note that your personal details and the data you provide will remain strictly anonymous and your responses will be collated with other respondents and presented to the sponsoring company in an aggregated or anonymized format with no attributions made to individuals.

May I proceed with asking you some questions to determine if you qualify? It should only take a couple minutes of your time.

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* 7. What is your date of birth?

Date

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* 8. What is your current age?

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* 9. What gender do you identify as?

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* 10. What state do you reside in?

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* 11. As of today, what type of health insurance, if any, do you have? Select all that apply.

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* 12. Which of the following medical conditions have you ever been officially diagnosed with by a healthcare professional? Select all that apply.

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* 13. You indicated that you have been diagnosed with lupus (systemic lupus erythematosus (SLE)). Have you also been told by a healthcare professional that you have lupus nephritis (an inflammation of the kidneys caused by lupus)?

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* 14. What tests were used to determine your kidneys were being impacted by your lupus? Please select all that apply.

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* 15. What types of healthcare professional(s) do you see to manage your Lupus treatment and/ or lupus nephritis (an inflammation of the kidneys caused by lupus) treatment? (Select all that apply)

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* 16. In the past 12 months, how many times have you visited the following healthcare professional(s) who manages your…

  Lupus Treatment
# of visits (Past 12 months) 		Kidney treatment
# of visits (Past 12 months)
Rheumatologist
Dermatologist
Family doctor/ General practitioner
Internal medicine
Nephrologist

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* 17. What treatments have you ever received or are currently receiving to treat your lupus.

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* 18. Have you ever participated in clinical research for your lupus or lupus nephritis? There are 2 main types of clinical research: Clinical trials, also called interventional studies and Observational studies. The main difference is if researchers assign participants to get an intervention, such as a drug, behavior, or medical device. In clinical trials, researchers do assign participants one of more interventions. In observational studies, researchers do not assign participants to an intervention. Some observational studies use patient registries. A patient registry is an organized collection of data that patients agree to give.

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* 19. To make sure all groups are represented equally I am going to start by asking some general demographic questions. Some questions can be sensitive in nature. We would like to remind you that your participation is voluntary and that your responses are used for research purposes only. A “Prefer not to answer” option is available for you to select, if applicable.

Which races, ethnicities, or origins describe you? (Select all that apply)

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* 20. Do you identify as Hispanic, Latino/ Latina, or of Spanish origin.

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* 21. We want to make sure you're comfortable during our conversation. Could you please let us know which language you would prefer for this interview? Select both if you do not have a preference:

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* 22. What is your marital status?  Are you...

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* 23. How many people total live in your household, counting all children and adults including yourself?

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* 24. Which of the following groups comes closest to your yearly household income?

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* 25. Which of the following applies to you?

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* 26. What is the highest level of education you, yourself, completed?

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* 27. May we re-contact you for additional questions for clarification relating to this project?

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* 28. Some of your research responses, including written materials, photos, or edited versions of the interview recordings (audio or video) may be used in presentation of the research findings to Ipsos staff and/or the pharmaceutical sponsor’s staff. These materials as described above may also be used by the pharmaceutical company with external parties for educational purposes. Your name and contact information would not be disclosed; all information would be anonymized. Your video footage will not be used for advertising or promotional purposes and will not be openly available on the internet.

You will receive $125 per day for your participation in the market research.

Please confirm that you have understood the above and that you agree to take part in this project on this basis.

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* 29. With your permission, which we will ask for at the end of this explanation, the interview may be listened to or viewed by client pharmaceutical company staff live via audio or video streaming. It may also be recorded for additional analysis at a later stage. The recording or its transcripts may be passed on to the sponsor in an anonymous form only for internal use.

Do you consent to recording of this interview?

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* 30. Are you willing to participate in this interview with the understanding that your interview may be viewed or listened to by client company staff?

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* 31. This research session will take place over the phone and on the Internet utilizing a web sharing platform. The following questions will help us determine if your computer is able to use the technology.

For the interview, it would be ideal that you are in front of a laptop or desktop computer which has a high-speed internet connection to participate in the interview. During the interview, you may be asked to view materials online (Video/Images). Will you have access to a laptop or desktop computer with a webcam and high-speed internet during the interview?

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* 32. Do you agree to testing your computer at least 24 hours prior to your scheduled interview to ensure that your system is working properly?

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