Biotech Treatment Trial Participant Feedback
Please provide your feedback and experience regarding your participation in the biotech treatment trial.
Participant Name
*
First Name
Last Name
Email Address
*
example@example.com
Date of Participation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Which treatment or study group were you assigned to?
*
Please Select
Group A (Active Treatment)
Group B (Placebo)
Other/Not Sure
Please rate the following aspects of your experience in the trial:
*
Rows
Very Poor
Poor
Fair
Good
Excellent
Communication from trial staff
1
2
3
4
5
Clarity of instructions
6
7
8
9
10
Comfort during treatment
11
12
13
14
15
Ease of scheduling appointments
16
17
18
19
20
Did you experience any side effects during the trial?
*
Yes
No
If yes, please specify the side effects you experienced:
How satisfied are you with the outcome of the treatment you received?
*
1
2
3
4
5
How likely are you to recommend participation in this trial to others?
*
Not Likely
1
2
3
4
5
6
7
8
9
Very Likely
10
1 is Not Likely, 10 is Very Likely
Please provide any additional comments or suggestions regarding your experience in the trial.
Submit Feedback
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