Information form for Pharmaceutical Company Use of the UC-PRO

Name*

First Last

Title / Degree*

Affiliation*

Company Department City State / Province / Region ZIP / Postal Code Country

Email Address*

Which UC-PRO modules and mode of administration do you plan to use?*

Select All
Signs and Symptoms
Systemic Symptoms
Coping Strategies
Daily Life Impact
Emotional Impact

Signs and Symptoms*

Handheld ePRO device
Tablet
Web Based
BYOD (in include smart phone)
Paper/pencil
Currently undecided

Systemic Symptoms*

Handheld ePRO device
Tablet
Web Based
BYOD (in include smart phone)
Paper/pencil
Currently undecided

Coping Strategies*

Handheld ePRO device
Tablet
Web Based
BYOD (in include smart phone)
Paper/pencil
Currently undecided

Daily Life Impact*

Handheld ePRO device
Tablet
Web Based
BYOD (in include smart phone)
Paper/pencil
Currently undecided

Emotional Impact*

Handheld ePRO device
Tablet
Web Based
BYOD (in include smart phone)
Paper/pencil
Currently undecided

If ePRO is planned, who will be your ePRO provider?*

Describe phase and type of study*

Describe the purpose of use for the UC-PRO/SS*

Detail the purpose and use for the UC-PRO additional modules*

What Language Versions do you require?*

To contact Evidera with your inquiry, please complete the form above. Fields marked with * are required. Pharmaceutical Product Development, LLC and its affiliates including Evidera (together "PPD") will use the information you provide on this page for the purpose of reaching out to you and responding to your inquiry. Important information on how PPD handles personal data and what rights you may have under data privacy laws are included within PPD's Global Privacy Policy.