Information Form for Pharmaceutical Company Use of the PSI

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Please complete the form below to provide additional information about use of the PSI for pharmaceutical companies and someone from our team will be in touch soon.

"*" indicates required fields

Name*

First Last

Title / Degree*

Affiliation*

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

Email Address*

Which version of the PSI are you interested in?*

Past 24-hour recall (accumulates 7 days to a weekly diary score)

Past 7 days recall (patient retrospective report to create a past week score)

Which mode of administration do you plan?*

Handheld ePRO device

Tablet

Web Based

BYOD (to 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 PSI*

What Language Versions do you require?*

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