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* 1. Introduction and Terms & Conditions. 

Thank you for your interest in our cardiovascular and chronic kidney disease study (“Study”) about the treatment journeys of patients with heart and kidney related conditions.

For the purposes of this form, “personal data” means any data relating to you as a patient, like your contact details and responses provided in the course of participating in the Study.

If you choose to participate in the Study, you will need to read/listen to the following information carefully and provide your consent.

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* 2. Data Sharing Consent, incl. permission to observe and record

As mentioned above, the research may be observed, recorded, and listened to for research purposes by representatives from the Study sponsor. Those representatives must respect the confidentiality of all information collected in market research interviews/groups and you will not be marketed to on the basis on your participation in this research. The information that you provide is confidential and your identity will not be revealed to the sponsor unless you give written permission allowing them to do so. All survey answers will be summarized and reported an anonymously. You have the right to refuse to answer any question or decide not to participate at any time. The Study sponsor will comply with all applicable data protection and privacy laws, together with any applicable guidelines (including General Data Protection Regulation (GDPR) and with local data privacy regulations, Market Research Society (MRS), ESOMAR, European Pharmaceutical Marketing Research Association (EphMRA), and applicable global codes of practice.

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* 3. US Only: Adverse Events reporting

We are required to pass on to the pharmaceutical company sponsoring the study details of adverse events, and/or other safety information - now referred to as safety information - that are mentioned during this study. Although what you say will, of course, be treated in confidence, should you mention safety information during the study, we will need to report it, even if you, or your Doctor, has already reported it directly to the company or the regulatory authorities.

In relation to reporting safety information, 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:

a) Any personal data in relation to the safety information reported will be forwarded to the project sponsor; and

b) 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; and

c) 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.

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. 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 study. If you do so, you can still participate in this study.

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* 4. Are you happy to proceed with this study?

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