Pre-Interview Questionnaire

Name Phone Number

for Interview
Title

Name of Organization

Email Address

Address for Honorarium

1. In what country do you primarily practice or work?

Honduras
Ghana
Nigeria
Kenya
Uganda
Tanzania
Malawi
Indonesia
Cambodia
Other (please specify: _______)

2. Which of the following best describes your current or former role?

Infectious disease specialist (labeled as Physician in guide)

Physician with other medical specialty (please specify: ______) (labeled as Physician in guide)
Hospital administrator (please specify title: ______) (labeled as Hospital in guide)
Public health researcher (labeled as Public Health KOL in guide)
Former public health official and / or government employee (labeled as Government in guide)
Former payer (labeled as Payer in guide)
NGO administrator (labeled as NGO in guide)
Other (please specify: _______)

3. In the past five years, have you authored or co-authored any peer-reviewed publications, action
plans, or guidelines regarding infectious diseases excluding HIV and malaria (i.e. tuberculosis,
pneumonia, diarrheal diseases)?

Yes (please specify: ______)

No

4. Have you been involved in any professional societies, committees, or advisory boards dedicated to
infectious diseases excluding HIV and malaria (i.e. tuberculosis, pneumonia, diarrheal diseases)
within your institution or country?

Yes (please specify: ______)

 No

5. [If options 1-3 selected in Q2] Please select your primary setting of care.
Tertiary hospital
Community hospital
Hospital-affiliated clinic
Non-hospital clinic/setting (e.g., health centre II, III, IV)
Other (please specify: _______)

6. [If options 1-3 selected in Q2] Is your setting of care a teaching hospital? A teaching hospital means
an institution that is affiliated with a medical school in which medical students receive training.
Yes [Prioritize for KOLs]
No

7. [If options 1-2 selected in Q2] How many years have you been in practice since completing
residency training? 4 Years [Screen out if <3 years]

8. [If options 1-2 selected in Q2] What percentage of your time is spent in direct patient care? [Screen
out if <30%] 50%

9. [If options 1-3 selected in Q2] Please estimate your institution’s number of beds: __25__ beds

10. Please indicate your level of familiarity with the following: [Screen out if ‘Not familiar’ selected for
all 3 rows]

Level of familiarity
Very familiar Somewhat familiar Not familiar
National, local or
regional programs /
11. policies to treat or o o o [If
prevent infectious
diseases
Institutional
programs / policies to
o o o
treat or prevent
infectious diseases
Local NGOs dedicated
to treating or
o o o
preventing infectious
diseases

option 5 selected in Q2] How recently did you serve as a government official?
Current Member [Screen out]
Former Member, <5 years ago [Prioritize]
Former Member, >5 years ago

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12. Besides HIV, malaria, or tuberculosis, what are the three infectious diseases with the highest burden
of disease in your country?

13. Patient safety monitoring is important to our client. We are required to pass on to our client details
of adverse events experienced by one or more of your patients while on one of our client's products
that may be mentioned during the course of this market research. Although your answers will be
treated in confidence, should you raise an adverse event, we will need to report this information to
our client’s drug safety department, even if it has already been reported by you directly to the
company or the regulatory authorities. All information forwarded to our client’s drug safety
department is treated in accordance with local privacy laws and may be captured and processed in
countries outside of the national territory, and shared with health authorities or other
pharmaceutical companies with whom our client has a license agreement, in order to meet the
regulatory requirements for reporting safety information on our client's products.

Do you agree to participate in this study on this basis?

o Yes
o No [Screen out immediately]

14. In case you highlight an adverse event during this market research, we would file a report without
giving any of your details, but if the Drug Safety Department requires more information, would you
be willing to waive the confidentiality given to you under the Market Research Codes of conduct
specifically in relation to that adverse event, so they can contact you directly for further
information? Please note that if you provide your name during the Adverse Event reporting, this will
not be linked in any way to the responses given during the market research and everything else you
say during the survey will continue to remain confidential.
o Yes, I am willing to waive my confidentiality given to me under the Market Research Codes
of conduct should an adverse event be identified so that I can be contacted for further
information
o No, I am not willing to waive my confidentiality should an adverse event be identified in the
answer I provide [DO NOT TERMINATE, ALLOW TO PROCEED]

Please indicate you available timeslot (Pick two time slots)

March 9, 3 PM to 10 PM Ghana time -

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March 10, 3 PM to 10 PM Ghana time
March 11, 3 PM to 10 PM Ghana time
March 12, 3 PM to 10 PM Ghana time
March 13, 3 PM to 10 PM Ghana time
March 16, 3 PM to 10 PM Ghana time
March 17, 3 PM to 10 PM Ghana time
March 27, 3 PM to 10 PM Ghana time