Provider-Administered Therapy Participant Survey

Participant Questionnaire

Thank you for your interest in participating in a 90-minute online / Zoom focus group aimed to understand the experience, challenges and opportunities for support around provider administered therapies (ex. infusion or injection medications given at a medical facility).

All information collected as part of this questionnaire is private and will be securely stored and then deleted within 45 days.

Question Title

* 1. Please select which gender you identify as

Female

Male

Transgender

Non-binary or non-conforming

Other (please specify)

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* 2. Which of the following best describes your ethnicity (select all that apply)

Caucasian

African American

Asian

Asian Pacific

Native American

Other (please specify)

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* 3. What type of medical insurance are you currently using?

Corporate Insurance (e.g., HMO, PPO, HSA)

Government Insurance (e.g., Medicare, Medicaid)

No insurance

Other (please specify)

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* 4. Which of the following applies to you (Select all that apply)

I am currently receiving a provider administered medication (ex. infusions or injections)

I have received a provider administered medication in the past

My doctor has presented provider administered medications as an option for my care, but I have not received them

None of the above

Other (please specify)

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* 5. What type of provider administered medication did you receive? (Select all that apply)

Infusion

Injection

Other (please specify)

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* 6. What diagnosis / disease(s) did you receive a provider administered medication for? (Select all that apply)

Crohn's Disease

Ulcerative Colitis

Multiple Sclerosis (MS)

Lupus

Cancer

Other (please specify)

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* 7. Please list the name of the medication(s) you received via a provider administered treatment.

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* 8. When was the last time that you received a provider administered medication

Within the last six months

Within the last year

1 to 5 years ago

Greater than 5 years ago

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* 9. Where did you receive your provider administered medications? (can be a specific location or the location type)

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* 10. Are you willing to participate in a 15 minute call with a member of our research team prior to the virtual focus group?

Yes

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* 11. Are you available to participate in a 90-minute virtual focus group the week of October 10th or the week of October 17th? (Exact dates and times to be confirmed)

Yes

Other (please specify)

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* 12. Please complete your contact information

Name

Email Address

Phone Number

Thank you for completing the Participant Questionnaire! If your profile is a match, a member of our research team will reach out to complete a 15 minute screening call.

All participants who are selected to participate in the upcoming 90-minute focus group will receive a $50 Visa gift card.

Provider-Administered Therapy Participant Survey

Participant Questionnaire

Question Title

* 1. Please select which gender you identify as

Question Title

* 2. Which of the following best describes your ethnicity (select all that apply)

Question Title

* 3. What type of medical insurance are you currently using?

Question Title

* 4. Which of the following applies to you (Select all that apply)

Question Title

* 5. What type of provider administered medication did you receive? (Select all that apply)

Question Title

* 6. What diagnosis / disease(s) did you receive a provider administered medication for? (Select all that apply)

Question Title

* 7. Please list the name of the medication(s) you received via a provider administered treatment.

Question Title

* 8. When was the last time that you received a provider administered medication

Question Title

* 9. Where did you receive your provider administered medications? (can be a specific location or the location type)

Question Title

* 10. Are you willing to participate in a 15 minute call with a member of our research team prior to the virtual focus group?

Question Title

* 11. Are you available to participate in a 90-minute virtual focus group the week of October 10th or the week of October 17th? (Exact dates and times to be confirmed)

Question Title

* 12. Please complete your contact information

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* 13. Where did you learn about this survey?