Form 1 2021 ClinicalTrials.gov User Sign-up

Share your thoughts on a website about clinical trials

We’re looking for people to read and share their thoughts on a website about clinical trials. By
sharing your opinions, you’ll help us improve the website to make it easier for others to
understand and use.
If you’re interested, fill out the form below.
If we select you to take part, we will email you to:
•
Send you the website to review
•
Schedule a virtual interview that will last up to 1 hour through a phone call or Zoom

OMB Control Number: 0925-0648
Expiration Date: 05/31/2021
Public reporting burden for this collection of information is estimated to average 2 minutes per
response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of
information. An agency may not conduct or sponsor, and a person is not required to respond to,
a collection of information unless it displays a current valid OMB control number. Send
comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to NIH, Project Clearance Branch, 6705
Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0648). Do not return
the completed form to this address.

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* Required
1. What is your first name? *

Enter your answer

2. What is your age? *
Enter a whole number, such as 45.
Enter your answer

3. Which of these best describes your ethnicity? *
Choose one.
Hispanic or Latino
Not Hispanic or Latino

4. How would you identify your race or ethnicity? *
Choose all that apply.
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White

5. What is your gender? *
Male
Female
Prefer not to say

6. What is your highest level of education? *
8th grade or less
Some high school
Graduated high school or GED
Vocational or Trade school
Associate degree
Bachelors degree
Graduate or professional degree
Other

7. What is your employment status? *
Full-time
Part-time
Retired
Unemployed
Prefer not to say

8. Do you work in a health or medical-related field? *
Yes
No

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