Peanut Allergy Clinical Trial Questionnaire

Thank you for your interest. This is a Phase II clinical study to find out if an investigational drug could prevent severe allergic reactions in people with Peanut Allergy and aged 18-55.

This study will last up to 3 months, with a 1-month treatment stage. The investigational drug is a twice-daily oral pill.

To see if you qualify for this trial, please take 5 minutes to complete the questionnaire below. Completing this online questionnaire does NOT obligate you to participate in the peanut allergy clinical trial.

1. How old are you? (Example: 45)

2. Have you been diagnosed by a medical doctor with a Peanut Allergy?

Yes

No

3. Are you currently participating in another clinical study?

Yes

No

4. Do you have any of the following conditions?

Heart Disease (e.g., heart attack, heart failure, stroke)

Cancer

Liver or Kidney Disease

History of alcohol or drug abuse

None of the above

5. Are you pregnant or planning on becoming pregnant in the next 3 months?

Yes

No / Not applicable

6. What is your race? This question is completely optional: if you don’t want to answer it, select the “I don’t want to answer” option. ?

Why are we asking this question?

We are collecting this information in an effort to monitor if our patient recruitment materials reach a diverse audience as part of our effort to increase diverse representation in our clinical trials. Diverse, inclusive trials are critical to understanding how certain patient populations may respond to a particular treatment or medicine. They also help to identify and address unique circumstances that may arise in different patient populations while on therapy or taking a medication. Your race or ethnic group does not determine eligibility for the trial.

White

Black / African American

Asian

American Indian or Alaska Native

Native Hawaiian or Pacific Islander

Other

I don’t want to answer

7. What is your ethnic group? This question is completely optional: if you don’t want to answer it, select the “I don’t want to answer” option. ?

Why are we asking this question?

We are collecting this information in an effort to monitor if our patient recruitment materials reach a diverse audience as part of our effort to increase diverse representation in our clinical trials. Diverse, inclusive trials are critical to understanding how certain patient populations may respond to a particular treatment or medicine. They also help to identify and address unique circumstances that may arise in different patient populations while on therapy or taking a medication. Your race or ethnic group does not determine eligibility for the trial.

Hispanic or Latino

Not Hispanic or Latino

Unknown

I don’t want to answer

8. What is your zip code?