COPD Research Study – Screening Questionnaire

What is your full name?

What is your email address?

What is your phone number?

What is your date of birth?

Format: Month/Day/Year (e.g., 06/15/1962).

What is your home street address?

Your address and ZIP code are used to match you with the nearest study site — you will not need to choose a site yourself.

What city do you live in?

What state do you live in?

North Carolina New York Pennsylvania Tennessee Other state or territory

What is your ZIP code?

Are you willing to be contacted about future research studies?

Yes No

What types of studies would you be interested in?

List comma separated keywords

This is a clinical research study. Taking part is completely voluntary. Anyone in the study can ask questions at any time and choose to stop without any penalty. Do you understand this?

Yes No

Are you between 40 and 80 years old?

Yes No

Has a healthcare provider diagnosed you with chronic obstructive pulmonary disease (COPD)?

Yes No Not sure

Has your COPD diagnosis been in place for at least 1 year?

Yes No Not sure

Are you currently using a daily or regular maintenance inhaler for COPD?

Yes No Not sure

Which of the following best describes your current COPD maintenance treatment? Select all that apply.

Inhaled corticosteroid (ICS) Long-acting beta agonist (LABA) Long-acting muscarinic antagonist (LAMA) Combination inhaler Multiple maintenance inhalers Other maintenance inhaler Not sure which medications are in my inhaler(s)

Has your current COPD maintenance inhaler treatment been used for at least 3 months in a row?

Yes No Not sure

In the past 12 months, how many times did your COPD get significantly worse and require extra medical treatment — such as a course of steroids, antibiotics, an emergency room visit, or a hospital stay?

None 1 time 2 times 3 or more times Not sure

In the past 12 months, did a COPD flare-up lead to an emergency room visit or a hospital stay?

Yes No Not sure

In the past 12 months, did a COPD flare-up require a course of oral or injected steroids — for example, prednisone?

Yes No Not sure

Did at least one COPD flare-up happen while you were already using a regular COPD maintenance inhaler?

Yes No Not sure Not applicable

Which best describes your history of cigarette smoking?

Current smoker Former smoker Never smoked cigarettes

About how many total years did your cigarette smoking last (or has it lasted so far)?

On average, about how many packs of cigarettes per day did you smoke — or do you smoke now?

For example: half a pack = 0.5, one pack = 1, two packs = 2.

Has a doctor ever diagnosed you with asthma — including asthma as a child?

Yes No Not sure

Has a doctor ever diagnosed you with asthma-COPD overlap syndrome — sometimes called ACOS?

Yes No Not sure

Besides COPD, has a doctor diagnosed you with another significant lung or breathing condition?

Yes No Not sure

Have you received treatment for tuberculosis (TB) in the past 12 months?

Yes No Not sure

Has a doctor ever diagnosed you with cancer or another malignancy?

Yes No Not sure

Do you currently have a serious, unstable, or poorly controlled health condition other than COPD?

Yes No Not sure

Are you currently taking any medication that suppresses or changes how the immune system works — for example, steroids taken by mouth, methotrexate, or biologics?

Yes No Not sure

Are you currently taking a macrolide antibiotic on a regular basis — for example, azithromycin or clarithromycin?

Yes No Not sure

Do you currently use long-term oxygen therapy at home?

Yes No

What is your usual prescribed oxygen flow rate?

1 litre per minute or less More than 1 up to 2 litres per minute More than 2 up to 4 litres per minute More than 4 litres per minute Not sure

While using your prescribed oxygen, is your blood oxygen level usually below 89%?

Yes No Not sure

Are you currently taking part in another clinical research study, or have you taken part in one in the past 30 days?

Yes No Not sure

Clinical research studies like this one may include a placebo — meaning some participants receive an inactive treatment rather than the study treatment. All participants receive close medical monitoring throughout the study. Would you be willing to take part knowing you might receive a placebo?

Yes No

Are you willing to continue your current COPD medications as directed by the study team for the length of the study?

Yes No

Are you willing to be re-contacted by the study team if they need to confirm any answers or share next steps?

Yes No