Clinical Trial Enrollment Barrier Assessment Form
Help us understand potential barriers to your participation in a clinical trial. Your responses are confidential and will guide our support efforts.
Preferred contact method
*
Phone
Email
Text message
Mail
Other
How did you hear about this clinical trial?
*
Doctor or healthcare provider
Family or friends
Online search
Social media
Flyer or poster
Community event
Other
Have you completed the eligibility screening for this trial?
*
Yes
No
Not sure
How much does transportation impact your ability to participate?
*
1
2
3
4
5
How challenging is it for you to fit study visits into your schedule?
*
1
2
3
4
5
Do you have childcare or caregiver responsibilities that may affect your participation?
*
Yes, childcare responsibilities
Yes, caregiver responsibilities
Both childcare and caregiver
No
How much does the distance or travel required for study visits affect your willingness to participate?
*
Not at all
1
2
3
4
A great deal
5
1 is Not at all, 5 is A great deal
Please rate how much each of the following may be a barrier for you
*
Rows
Not a barrier
Minor barrier
Major barrier
Language or understanding of study materials
1
2
3
Technology or internet access
4
5
6
Do you have reliable access to the internet or a device for study participation (e.g., for virtual visits or communications)?
*
Yes, always
Sometimes
No
Please describe any other barriers or support you may need to participate in this clinical trial.
Submit Assessment
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