Site Feasibility Survey CorEvitas Alopecia Areata (AA) Registry

IMPORTANT: Please complete all questions on this feasibility survey using best efforts to provide accurate enrollment projections and medication use in your practice. The use of your EMR or other technology dashboards in providing these numbers will greatly assist with appropriate site selection and setting enrollment and study conduct expectations customized to your practice.

Question Title

* 1. General Information

Principal Investigator Name

Principal Investigator Email

Institution/Practice Name

Full Address

Primary Contact Name

Primary Contact Title

Primary Contact Email

Primary Contact Phone

Practice Website

Question Title

* 2. Site Facility Information
What is the site/facility type that would be used for this registry?

Private Practice

Academic Practice

Community Practice

Question Title

* 3. Please describe your overall interest in joining the Alopecia Areata (AA) Registry.

Low

Moderate

High

Question Title

* 4. CorEvitas prefers at least one sub-investigator, apart from the Principal Investigator, to participate. Please enter the total number of providers (including the PI) that you anticipate will participate in this registry research.

Total Number of Providers

Question Title

* 5. Will your site be managed by a SMO for this study?

Yes

If yes, which SMO?

Question Title

* 6. Will your site be managed by a SMO for this study?

Yes

If yes, which SMO?

Question Title

* 7. Will dedicated Research staff be assigned to the CorEvitas Alopecia Areata Registry?

Yes

Question Title

* 8. Does your site have digital devices (e.g., desktop/laptop computers, tablets) that could be used for direct data entry by registry subjects?

Yes

Question Title

* 9. We would like to understand the standard of care for seeing patients with alopecia areata. What is the typical frequency of visits?

every 3 months

every 6 months

every 12 months

Other (please specify)

Question Title

* 10. When patients switch treatments for alopecia areata, is the patient brought in for a visit?

Yes

Question Title

* 11. **Subject Population - Please use your best estimate when completing this section for your practice (defined as all anticipated participating providers*).**

How many adult patients with alopecia areata [ICD-10-CM L63.9] does your practice treat on an annual basis?

On average, how many new adult patients with alopecia areata [ICD-10-CM L63.9] does your practice treat on an annual basis?

How many adolescent patients (aged 12-15) with alopecia areata [ICD-10-CM L63.9] does your practice treat on an annual basis?

On average, how many new adolescent patients (aged 12-15) with alopecia areata [ICD-10-CM L63.9] does your practice treat on an annual basis?

From your practice’s alopecia areata population, how many do you estimate to have moderate to severe disease?

What percent of the adult patients with alopecia areata treated by your practice have >20% scalp hair loss?

How many adult patients with alopecia totalis [ICD-10-CM L63.0] or alopecia universalis [ICD-10-CM L63.1] does your practice treat?

In the last 12 months, how many unique adult alopecia areata patients in your practice* have been treated with intralesional corticosteroids?

In the last 12 months, how many adult alopecia areata patients in your practice* have been treated with either methotrexate or cyclosporine?

In the last 12 months, how many adult alopecia areata patients in your practice* have been treated with oral JAK inhibitors (e.g., tofacitinib, baricitinib, upadacitinib, ruxolitinib)? If your site does AA clinical trials, do not include clinical trial patients in this estimate.

In the next 12 months, how many adult patients do you anticipate prescribing an intralesional corticosteroids for the treatment of alopecia areata?

In the next 12 months, how many adult patients do you anticipate prescribing either methotrexate or cyclosporine for the treatment of alopecia areata?

In the next 12 months, how many adult patients do you anticipate prescribing an oral JAK inhibitor for the treatment of alopecia areata?

If you do participate in alopecia areata clinical trials, how many patients in your practice* are in clinical trials?

Question Title

* 12. Reason for Participation
Which are your reasons for wanting to participate in a CorEvitas' Registry? Please check all that apply.

Academic recognition/Publication potential

Contribution to improving understanding of safety and effectiveness of approved therapies for this indication in real-world settings outside of clinical trials

Engage my patients in monitoring their own health status and progress

Contribution to educational and clinical knowledge or enrichment of the medical community

Opportunity to establish database of my patient population

Monetary supplement to existing Medicare/Insurance fee schedules

Other (please specify)

Question Title

* 13. Referral
How did you learn about the CorEvitas Alopecia Areata Registry?

Dermatologist referral (please provide referral name in Other)

Speaker presentation (please specify name of presenter in Other)

Pharma/biotech company meeting (please specify in Other)

Foundation communication or website (please specify in Other)

Speaker presentation (please specify in Other)

Clinical Study or IRB referral network

Site Management Organization (please specify in Other)

Direct Invitation from CorEvitas

Other (please specify)

Question Title

* 14. Please provide name and contact information of person completing this survey below:

Name:

Preferred Contact Information:

Title:

Please email completed survey to alopecia@corevitas.com if not completing online.

Site Feasibility Survey CorEvitas Alopecia Areata (AA) Registry

Question Title

* 1. General Information

Question Title

* 2. Site Facility InformationWhat is the site/facility type that would be used for this registry?

Question Title

* 3. Please describe your overall interest in joining the Alopecia Areata (AA) Registry.

Question Title

* 4. CorEvitas prefers at least one sub-investigator, apart from the Principal Investigator, to participate. Please enter the total number of providers (including the PI) that you anticipate will participate in this registry research.

Question Title

* 5. Will your site be managed by a SMO for this study?

Question Title

* 6. Will your site be managed by a SMO for this study?

Question Title

* 7. Will dedicated Research staff be assigned to the CorEvitas Alopecia Areata Registry?

Question Title

* 8. Does your site have digital devices (e.g., desktop/laptop computers, tablets) that could be used for direct data entry by registry subjects?

Question Title

* 9. We would like to understand the standard of care for seeing patients with alopecia areata. What is the typical frequency of visits?

Question Title

* 10. When patients switch treatments for alopecia areata, is the patient brought in for a visit?

Question Title

* 11. Subject Population - Please use your best estimate when completing this section for your practice (defined as all anticipated participating providers*).

Question Title

* 12. Reason for ParticipationWhich are your reasons for wanting to participate in a CorEvitas' Registry? Please check all that apply.

Question Title

* 13. ReferralHow did you learn about the CorEvitas Alopecia Areata Registry?

Question Title

* 14. Please provide name and contact information of person completing this survey below:

* 2. Site Facility Information
What is the site/facility type that would be used for this registry?

* 11. **Subject Population - Please use your best estimate when completing this section for your practice (defined as all anticipated participating providers*).**

* 12. Reason for Participation
Which are your reasons for wanting to participate in a CorEvitas' Registry? Please check all that apply.

* 13. Referral
How did you learn about the CorEvitas Alopecia Areata Registry?