Virtual Chronic Hepatitis B Patient and Caregiver Council / Comité virtuel de patients atteints d'hépatite B chronique et de proches aidants Please select your preferred language for documentation: English / Anglais French / Français 1) First Name Last Name Email address 2) Are you 18 years of age or older? Yes No 3) Do you reside in Canada? Yes No In what province/territory do you reside? - Select -AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaOntarioPrince Edward IslandQuebecSaskatchewanNorthwest TerritoriesNunavutYukon 4) Have you been diagnosed with chronic hepatitis B or are you the caregiver of someone who has been diagnosed with chronic hepatitis B? I have been diagnosed with chronic hepatitis B I am the caregiver of someone who has been diagnosed with chronic hepatitis B None of the above 5) How long have you been diagnosed with chronic hepatitis B? < 1 year 1-5 years 6 years or more 6) Are you on treatment for chronic hepatitis B? Yes No How long have you been on treatment for chronic hepatitis B? < 1 year 1-5 years 6 years or more 7) How old are you? 8) What is your sex? Male Female Prefer not to say 9) What is your ethnic background? African (for example: Nigerian, Ethiopian, Ghanaian, Somali) Asian (for example: Chinese, Indian, Filipino, Vietnamese, Korean) Caribbean (for example: Jamaican, Haitian, Trinidadian) European (for example: British, Irish, Italian, French, German, Polish) Central American or South American North American (for example: First Nations, Métis, Inuit, Canadian, American, Mexican) Oceanian (for example: Australian Aboriginal, Maori, Fijian, Samoan) Other ethnic or cultural background (please specify): Please specify: 5) How long has the person you are caring for been diagnosed with chronic hepatitis B? < 1 year 1-5 years 6 years or more 6) Is the person you are caring for on treatment for chronic hepatitis B? Yes No How long has the person you are caring for been on treatment for chronic hepatitis B? < 1 year 1-5 years 6 years or more 7) How old are you? How old is the person you are caring for? 8) What is your sex? Male Female Prefer not to say What is the sex of the person you are caring for? Male Female Prefer not to say 9) What is your ethnic background? African (for example: Nigerian, Ethiopian, Ghanaian, Somali) Asian (for example: Chinese, Indian, Filipino, Vietnamese, Korean) Caribbean (for example: Jamaican, Haitian, Trinidadian) European (for example: British, Irish, Italian, French, German, Polish) Central American or South American North American (for example: First Nations, Métis, Inuit, Canadian, American, Mexican) Oceanian (for example: Australian Aboriginal, Maori, Fijian, Samoan) Other ethnic or cultural background (please specify): Please specify: What is the ethnic background of the person you are caring for? African (for example: Nigerian, Ethiopian, Ghanaian, Somali) Asian (for example: Chinese, Indian, Filipino, Vietnamese, Korean) Caribbean (for example: Jamaican, Haitian, Trinidadian) European (for example: British, Irish, Italian, French, German, Polish) Central American or South American North American (for example: First Nations, Métis, Inuit, Canadian, American, Mexican) Oceanian (for example: Australian Aboriginal, Maori, Fijian, Samoan) Other ethnic or cultural background (please specify): Please specify: 10) Do you feel comfortable speaking and understanding English to take part in discussions and share your thoughts? Yes No Do you feel comfortable reading English to review patient council materials? Yes No Do you feel comfortable writing in English to take part in discussions online? Yes No 11) Do you feel comfortable speaking and understanding French to take part in discussions and share your thoughts? Yes No Do you feel comfortable reading French to review patient council materials? Yes No Do you feel comfortable writing in French to take part in discussions online? Yes No Comments / other preferred language(s): 12) Are you registered/licensed to practice, prescribe or dispense medicines? Yes No 13) Are you a patient or healthy volunteer currently participating in a GSK sponsored interventional clinical trial? Yes No 14) Do you or a close family member have any actual or perceived position of influence that could affect GSK business? Yes No