GSK COPD Study | Pre-Screener

Thank you for your interest in this COPD clinical research study. This set of questions will help us determine if you may be eligible to participate. The following questions will ask for specific and detailed information about your health, diagnosis, and medical history, as required by the study protocol. Your responses will be kept confidential and used solely to evaluate your potential eligibility for this study. Please answer each question as accurately as possible.

All information provided will be kept confidential in accordance with our Privacy Policy.

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Compliance & Consent Statement

By checking the box below and submitting this form, you acknowledge that you have read and understood the questions above and have answered them to the best of your ability.

You understand that this is a pre-screening questionnaire and does not guarantee your enrollment in the clinical study. A member of the research team will contact you to discuss your answers and potentially schedule a formal screening visit at the clinic, where final eligibility will be determined.

Consent to be Contacted:

By checking this box, you provide your express written consent for the study site and its research partners to contact you regarding this COPD research study and other clinical trial opportunities that may be of interest. You agree to be contacted via automated and manual phone calls, text messages, and/or email at the phone number and email address you provide, even if your number is on a do-not-call list. You understand that your consent is not a condition of receiving any treatment and that you can withdraw your consent at any time.

I have read, understood, and agree to the statements above.

GSK COPD Study | Pre-Screening Questionnaire

1. Are you between 40 and 75 years of age?

2. Have you been officially diagnosed with Chronic Obstructive Pulmonary Disease (COPD) by a healthcare provider for more than 12 months?

3. In the past 12 months, have you been hospitalized or stayed for observation for more than 24 hours in an emergency department or urgent care for your COPD?

4. In the past 12 months, have you had more than 2 COPD "flare-ups" (exacerbations) that required treatment with steroid pills/injections and/or antibiotics?

5. In the last 4 weeks, have you had a COPD "flare-up" (exacerbation) that was managed with steroid pills/injections and/or antibiotics?

6. As part of your daily standard care, do you take an inhaled medication containing either a LAMA (such as Spiriva®, Incruse®, Yupelri®) and/or a LABA (such as Serevent®, Brovana®, Perforomist®)?

7. Are you currently taking any of the following medications: phosphodiesterase inhibitors (e.g., roflumilast), leukotriene blockers (e.g., montelukast), or long-term macrolides (e.g., azithromycin)?

8. Do you currently use bilevel positive airway pressure (BiPAP) or long-term oxygen therapy?

9. Have you ever been diagnosed by a doctor with any of the following?

10. Which of the following best describes your history with cigarette smoking?

11. Have you been diagnosed with or treated for any of the following?

12. Have you received a COVID-19 vaccination?

13. Are you currently enrolled in another clinical study, or have you participated in one where you received an investigational drug, vaccine, or device within the last 30 days?

14. This research study lasts for approximately one year (52 weeks) and requires multiple visits to the study clinic, which will involve procedures like breathing tests, blood draws, and physical exams. Are you able and willing to commit to the full study duration and all required procedures?

Compliance & Consent Statement

Consent to be Contacted:

Unfortunately, you have not met the pre-screening requirements for this study.

Congratulations, you’ve met the pre-screening requirements!