Background Information

This section is intended to collect descriptive and background information on physician demographics, practice characteristics and patient population and determines clinical trial involvement.

Please tell us about yourself.

1. Gender       Male Female

2. Age

3. Please identify your race (select all that apply):

American Indian or Alaska Native
Asian
Hispanic or Latino
Black or African American
Native Hawaiian or Other Pacific Islander
White (non-Hispanic)
Some Other Race - please identify

4. Highest degree(s) you received and the years you received them in:

M.D. - Year Received
Ph.D. - Year Received
Masters- Year Received
Bachelors- Year Received
Other (specify) - Year Received

5. What board certifications do you currently have?

6. How many languages are you fluent in?

Please specify languages:

7. Medical specialty:

Sub-specialty (if applicable):

8. Have you received Good Clinical Practice (GCP) training and certification?

Trained?  Yes No

If yes, who provided the training?

Certified?  Yes No

If yes, who provided the certification?

 

Please tell us about your medical practice.

9. Practice location: City State Select... AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

10. Which of the following best describes the medical/research community that you presently serve?

Inner city
Urban
Suburban
Rural

11. Which of the following best describes your practice setting?

Private Practice
Group Practice
Community Health Clinic
Academic Medical Center
Unaffiliated Hospital
VA Hospital
Research Center/Consortium
Other - specify

12. Which of the following infrastructure items do you have in your practice?

Electronic medical records
Internet
Special record-keeping room/area
Specialized medical equipment (specify)

13. Are other people in your staff trained and certified in GCP?

Trained?  Yes No

If yes, who provided the training?

Certified?  Yes No

If yes, who provided the certification?

Please tell us about your patient population.

14. In your total practice (research plus private), how many patients do you serve?

Note: For questions 15-17, the aggregate percentages should approximate 100%.

15. Of these patients, how many are:

% Male
% Female

16. Approximately what percentage of the patients that you see are:

% American Indian or Alaska Native
% Asian
% Black or African American
% Hispanic or Latino
% Native Hawaiian or Other Pacific Islander
% White (non-Hispanic)
% Some other race - specify

17. Approximately what percentage of your patients are:

% Pediatric (17 or under)
% Adults (18 to 64)
% Geriatric (65 and over)

Please tell us about your involvement in clinical research.

18. Have you ever conducted/been involved in a clinical trial?  Yes No

19. If yes, in what capacity? (select all that apply)

Principal Investigator (PI)
Co-/Sub-investigator
Referring Physician
Other (specify)

20. If you refer your patients into clinical trials, on average, how many do you refer each year?

21. If you have never conducted/been involved in a clinical trial, how interested are you in participating in clinical trials?

	Very
	Somewhat
	Not at all

Your Ideas and Opinions

43. What are the top three reasons why you want to participate as an investigator in clinical trials?

1.
2.
3.

44. What are the top three concerns you have about participating as an investigator in clinical trials?

1.
2.
3.

45. Do you find that there are barriers to your participation as an investigator in clinical research?

 Yes No

If yes, please elaborate (select all that apply):

Lack of access: in the past I have not been invited to participate in clinical trials
Infrastructural needs in my office (i.e.: equipment, supplies, office design, etc.)
Personnel needs in my office (i.e.: dedicated study coordinator)
Time constraints (I do not have enough time to participate in clinical trials)
Grant payment amount not worth effort and record keeping required for clinical
      trial
My patients are not willing to participate
Other - specify:

46. If you mentioned that your patients are not willing to participate, which of the following reasons capture their reluctance? (select all that apply)

They do not trust the healthcare system
They do not trust the pharmaceutical/biotech industry
They have cultural barriers
      Please elaborate
They have religious beliefs that prevent their participation
They have language barriers
They have trouble paying for and/or securing transportation
They require child care
They believe the risks of the trial outweigh the benefits
Other - specify:

47. What factors do you think would motivate your patients to volunteer to participate in clinical research?

48. In your opinion, how important is your gender and race/ethnicity in influencing the willingness of patients of similar gender and race/ethnicity to participate in clinical trials?

Not Important
Somewhat Important
Important
Very Important

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Thank you for taking the time to respond to this survey. If we have additional questions for clarification and to elaborate, may we contact you?

	Yes
	No

Would you like to receive a summary report of the survey results?

	Yes
	No

Please provide the following contact information so that we can reach you if we have further questions and/or we can send you the survey results:

Name
Address
City
State	Select... AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Phone
Fax
Email

Best Time to Contact You
Mornings Afternoons Evenings

Best or preferred method of contact:
Phone Email Other (specify)