H.2037 Diabetes HCPs

You are about to fill in a short survey which will help determine your suitability to this research project. Please be aware that all data you provide us with will be held in accordance with the data protection policy outlined on our website. For further information please visit https://www.healthcareopinions.co.uk/privacy-policy/

What is your name, contact number and email address?

First Name
Surname
Contact Number
Email Address
Postcode

Please tell us your age.

Only numbers may be entered in this field.

Your answer must be between 1 and 99

Are you...

Choose one of the following answers

Male
Female
Prefer not to say
Other:

If applicable, what is your occupation?

Are your details currently registered with us? If you haven't, please do so here http://https://www.healthcareopinions.co.uk/

Choose one of the following answers

Where did you hear about this research participation opportunity?

Check all that apply

Email directly from Research Opinions
Recommended from a friend or family member
Healthcare Opinions website
Facebook
Instagram
Other:

What is your full job title?

Do you have experience prescribing insulin products and/or administering injections and/or teaching others how to perform injections during your daily work?

Check all that apply

Yes, prescribing
Yes, administering
Yes, training
No

In what type of setting do you work?

How is your eyesight? Do you have any vision impairments?

Check all that apply

Normal without correction
Reading glasses
Glasses
Contacts
Color blindness
Impairment

How does the impairment affect your ability to inject insulin, if at all?

How is your hearing?

Choose one of the following answers

Normal without correction
Impaired

Do you have a business or consulting relationship with a medical device or pharmaceutical company?

Have you ever participated in a study for an injection device? If so, when?

Choose one of the following answers

Yes, within the past year
Yes, more than a year ago
No

These next questions are additional COVID-related questions that we ask everyone to try and reduce the likelihood of exposure to, and spread of, COVID-19 for participants and study staff. You must answer all of these questions to be considered for the research study. But, if you are not comfortable answering, you may withdraw from this screening process and we will consider you for future studies that might not include these same questions.

1. Have you been fully vaccinated against the COVID-19 virus? (“Fully vaccinated” is defined as two weeks having passed after receiving the second dose of the Pfizer, Moderna, or AstraZeneca vaccine, or two weeks having passed after receiving the single dose of the J&J Janssen vaccine.)

Choose one of the following answers

Yes
Not yet but i will be by the study dates
No

Please think about how you have been feeling over the past 10 days. Have you tested positive for COVID-19 or had a fever or experienced or exhibited symptoms associated with COVID-19 (which include but are not limited to cough, shortness of breath, chills, muscle pain, sore throat)?

If you recently have experienced COIVD-19 symptoms, has it been more than 72 hours with no symptoms and no use of medications to treat symptoms?

Have you been in close contact with anyone who has tested positive for COVID-19 or who has experienced or exhibited COVID-19 symptoms within the past 14 days?

Have you or someone you live with traveled on an airplane in the last 10 days?

Do you plan to travel on an airplane in the near future?

Choose one of the following answers

Yes before the test dates
Yes after the test sessions
No

Are you involved in testing, diagnosing, and/or treating COVID-19 patients, or who live with someone who serves in such a role? This includes healthcare providers working in Emergency Rooms, Intensive Care Units, and Urgent Care settings, and first responders.

Are you immunocompromised? You might be immunocompromised if you have an immune deficiency or have HIV or AIDS that is not well controlled. For example, you might be immunocompromised if you have received cancer treatment, received or donated bone marrow or organs, or used corticosteroids and other immune weakening medications for a prolonged period of time.

Are you comfortable with us sharing your phone number with the study staff, so they can contact you on the day of your session?

A number of medical conditions are associated with higher risk for severe illness and death from COVID-19. If you have one or more of these conditions, you may be at higher risk for severe illness if you contract COVID-19, and we would like to bring these to your attention. If you answer yes to any of these questions, you are still eligible to participate in the study, but we want to notify you of the potential increased risk and let you decide whether you want to participate. As I go through each item, let me know if it is applicable to you

Do you have or have you been diagnosed with:

	Yes	No
Chronic kidney disease	Yes	No
Chronic lung diseases (e.g., COPD, moderate to severe asthma, interstitial	Yes	No
lung disease, cystic fibrosis, pulmonary hypertension	Yes	No
Dementia or other neurological conditions	Yes	No
Diabetes (type 1 or type 2)	Yes	No
Heart conditions (e.g., heart failure, coronary artery disease,	Yes	No
cardiomyopathies, hypertension)	Yes	No
Liver disease	Yes	No
Obesity	Yes	No

Are you pregnant or trying to become pregnant?