FDA Drug Safety Communications Questionnaire DRAFT
FDA DSC QUESTIONNAIRE SCREENER
[PROGRAMMER NOTE: Headings (internal use only) are in red. Programming instructions are in blue.
[GENERAL SCREENER]
[ASK ALL] [SINGLE CODE]
S1. What is your gender ?
_1 Male
_2 Female
[ASK ALL] [NUMERIC]
S2. What is your date of birth (year and month)?
YEAR
SINGLE PUNCH DROPDOWN PREQUAL
_[ACCEPTABLE RANGE FOR YEARS: 1910
...
_2000
[IF RESPONDENT UNDER 18 YEARS TERMINATE]
[ASK ALL] [OPEN ENDED]
S3. Please enter your zip code.
[CODE OPEN ENDED RESPONSE – 5 digits only]
[ASK ALL] [MULTI CODE]
S4. Are you trained or employed as (select all that apply):
[RANDOMIZE]
[ROWS]
Health care professional [IF YES TERMINATE]
Professional scientist or researcher [IF YES TERMINATE]
Educator
Electrician
Lawyer
[COLUMNS]
Yes
No
[ASK ALL] [MULTI CODE]
S5. Do you work in any of the following industries (select all that apply):
[RANDOMIZE]
[ROWS]
Pharmaceuticals [IF YES TERMINATE]
Advertising [IF YES TERMINATE]
Market research [IF YES TERMINATE]
Publishing
Energy
Engineering
[COLUMNS]
Yes
No
[CONDITION/DRUG USE SCREENER]
[ASK ALL] [SINGLE CODE]
C1. Have you ever been told by a doctor or other health professional that you have any of the following health problems (Select one for each)?
[RANDOMIZE]
[ROWS]
Asthma
Insomnia
Depression
Constipation
Diabetes or sugar diabetes
High blood pressure
[COLUMNS]
Yes
No
Not sure
[ASK IF FEMALE (2) @S1 AND IF YES (1) FOR “DIABETES OR SUGAR DIABETES” @C1] [SINGLE CODE]
C2. Other than during pregnancy, have you ever been told by a doctor or a health professional that you have diabetes or sugar diabetes? (Select one)
Yes
No
Not sure
[ASK ALL] [SINGLE CODE]
C3. Have you had any of the following symptoms in the last 3 months (Select one for each)??
[RANDOMIZE]
[ROWS]
Trouble having a bowel movement (straining) during at least 25% of bowel movements
Lumpy or hard stools in at least 25% of bowel movements
A sense that everything didn’t come out for at least 25% of bowel movements
Sensation of blockage for at least 25% of bowel movements
Needing help to have at least 25% of bowel movements (e.g., use of finger to assist, using hands to support rectal or vaginal muscles)
Fewer than three bowel movements per week
[COLUMNS]
Yes
No
Not sure
[PROGRAMMER: ELIGIBILITY FOR SURVEY
IF C1=”DIABETES” AND S1=”MALE”, THEN DIABETES-FLAG=1
IF C1 DOES NOT =”DIABETES” AND S1=”MALE” OR “FEMALE”, THEN DIABETES-FLAG=0
IF C1=”DIABETES” AND S1=”FEMALE” AND C2=YES, THEN DIABETES-FLAG=1
IF C1=”DIABETES” AND S1=”FEMALE” AND C2=NO OR NOT SURE, THEN DIABETES-FLAG=0
IF C1=”CONSTIPATION” OR TWO ITEMS=YES @C3, THEN CONSTIPATION-FLAG=1
IF C1 DOES NOT = “CONSTIPATION” OR LESS THAN TWO ITEMS=YES @C3, THEN CONSTIPATION-FLAG=0]
[PROGRAMMER: FILTERING INTO QUOTA CONDITION
IF DIABETES-FLAG=1 AND CONSTIPATION_FLAG=0, THEN QUOTA CONDITION=DIABETES
IF DIABETES-FLAG=0 AND CONSTIPATION_FLAG=1, THEN QUOTA CONDITION=CONSTIPATION
IF DIABETES-FLAG=1 AND CONSTIPATION_FLAG=1 AND BOTH CONDITIONS ARE OPEN, RANDOMLY ASSIGN QUOTA CONDITION
IF DIABETES-FLAG=1 AND CONSTIPATION_FLAG=1 AND ONE CONDITION IS CLOSE, ASSIGN TO OPEN CONDITION]
CLASSIFIED INTERNAL USE
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | RESPONDENT ID: __ __ __ __ __ |
| Author | Ipsos-NA |
| File Modified | 0000-00-00 |
| File Created | 2021-01-23 |