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CONFIDENTIAL DISCLOSURE

LIMITED USE AGREEMENT

for the Patient Assessment of Constipation Quality of Life Questionnaire
(Pac-Qol©)

THIS AGREEMENT WILL EXPIRE 7 DAYS AFTER RECEIPT.
THE COPY OF THE Pac-Qol SUPPLIED WITH THIS AGREEMENT MAY ONLY BE USED FOR EXAMINATION PURPOSES.
To view the questionnaire, please complete the following form:
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YOUR ACQUISITION OF AN EXAMINATION COPY OF PAC-QOL SIGNIFIES YOUR FULL AGREEMENT TO THE FOLLOWING CONDITIONS:

This License Agreement is for your limited use of the Patient Assessment of Constipation Quality of Life Questionnaire (Pac-Qol©) , ©Janssen Research Foundation, 1997, All Rights Reserved.

This Agreement provides you with a personal, non-transferable, royalty-free, non-exclusive right and license to use the Pac-Qol for limited purpose of examining the suitability of the Pac-Qol for subsequent research and/or clinical use. This Agreement does not include: (1) any license for use of the Pac-Qol in research or in clinical practice(2) any license to sell or sublicense use of the Pac-Qol . The Pac-Qol may be examined only by persons whom you employ or whom you engage as independent contractors. You assume all risk for use of the Pac-Qol. This License only entitles you to obtain and use, for examination purposes, a single copy of the Pac-Qol.

You are not authorized to modify, retype, translate, copy or otherwise duplicate the Pac-Qol except with the further and prior written permission of LICENSOR (Mapi Research Trust).

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