0847 MUMs Survey (English)

OMB Control No: 0910-0847 Expiration Date: 02/28/2026

Paperwork Reduction Act Statement: According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0910-0847. The time required to complete this information collection is estimated to average 20 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.

Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing burden to [email protected].

 

Multimorbidity and Medications: The Unheard Perspective of Older Adults

Introduction

 

We want to learn how people decide about joining research studies in which they take a medicine. This study is being conducted on behalf of the U.S. Food and Drug Administration (FDA). If you take part in the study, you will receive a $25 gift card as a token of appreciation after completion of the survey. The survey will take about 15 minutes. 

Your answers will be kept secure to the extent permitted by law.

By continuing, you agree to take part in this survey. Please scroll down and click the arrow button below to see if you are eligible!


Derjung Mimi Tarn, MD, PhD
Department of Family Medicine
University of California, Los Angeles

Janice B. Schwartz, MD
Department of Medicine
University of California, San Francisco
 

 

End of Block: Introduction

 

Start of Block: Screening Questions

 

Below are screening questions to see if you are eligible for the survey.

What is your age?

________________________________________________________________

 

 

 

A prescription medicine is one that you cannot buy on your own. A doctor needs to prescribe or give it to you. 
 
How many different prescription medicines do you take regularly by mouth or as a shot or patch?  (Enter number)

________________________________________________________________

 

 

 

Indicate if you have ever been diagnosed with the conditions below. (Mark ALL that apply)

▢ High cholesterol

▢ High blood pressure

▢ Diabetes (not prediabetes)

▢ Arthritis (joint problems)

▢ Osteoporosis 

▢ Heart attack, stents or bypass surgery

▢ Stomach ulcers, peptic ulcer disease or chronic heartburn 

▢ Heart failure

▢ Atrial fibrillation

▢ Chronic kidney disease

▢ Stroke

▢ Depression

▢ Cancer (other than skin cancers)

▢ Asthma or chronic obstructive pulmonary disease (COPD)

▢ Thyroid problems

▢ Liver disease or cirrhosis

▢ ⊗None of the above

 

 

Display This Question:

If Indicate if you have ever been diagnosed with the conditions below. (Mark ALL that apply) = Cancer (other than skin cancers)

 

What type of cancer? (Mark ALL that apply)

▢ Breast

▢ Prostate

▢ Lung

▢ Colon or rectal

▢ Bladder

▢ Lymphoma, leukemia, or other blood cancers

▢ Kidney

▢ Cervical / uterine

▢ Other

▢ ⊗Unsure

 

 

Display This Question:

If If Below are screening questions to see if you are eligible for the survey. What is your age? Text Response Is Less Than  65

Or Or A prescription medicine is one that you cannot buy on your own. A doctor needs to prescribe or gi... Text Response Is Less Than  5

Or Indicate if you have ever been diagnosed with the conditions below. (Mark ALL that apply) = None of the above

 

Sorry, you are not eligible for this survey. Thank you for your willingness to help!

Please enter your preferred contact information below if you would like us to contact you for future studies. (Write in ALL that apply)

• Email ________________________

• Phone________________________

• Mail _________________________

 

End of Block: Screening Questions

 

Start of Block: Survey questions

 

Congratulations! You are eligible for the survey. Let's get started!
 
The following questions are about you. 

 

 

Which of the following best describes you? (Mark ALL that apply)

▢ American Indian or Alaskan Native

▢ Asian

▢ Black or African American

▢ Native Hawaiian or Other Pacific Islander

▢ White

▢ Please fill in ________________________________________________

 ▢ Prefer not to answer

Do you consider yourself Hispanic/Latino or not Hispanic/Latino?

• Hispanic or Latino

• Not Hispanic or Latino

 

What is your current gender?

☐ Female

☐ Male

☐ Prefer not to answer

 

 

 

 

 

What is the highest degree or level of school you have completed?

• High school diploma or less

• Some college or associate degree

• Bachelor's degree

• Master's degree or above

 

 

 

What is your zip code?

________________________________________________________________

 

 

Page Break

 

   

 

Have you ever joined a research study or clinical trial in which you were asked to take a medicine?

• No

• Yes

 

Skip To: Q19 If Have you ever joined a research study or clinical trial in which you were asked to take a medicine? = No

 

Display This Question:

If Have you ever joined a research study or clinical trial in which you were asked to take a medicine? = Yes

 

Why did you join the research study or clinical trial? (Mark ALL that apply)

▢ My doctor recommended it

▢ A family member or friend recommended it

▢ To get a free medicine

▢ To help others

▢ To advance science and/or benefit society

▢ To get paid

▢ To try a different treatment

▢ Other (Write in) ________________________________________________

 

 

Display This Question:

If Have you ever joined a research study or clinical trial in which you were asked to take a medicine? = No

 

Have you ever been asked to join a research study in which you were asked to take a medicine?

• No

• Not sure

• Yes

 

 

Display This Question:

If Have you ever been asked to join a research study in which you were asked to take a medicine?... = Yes

 

Of the studies you were asked to join, did you consider joining any of them?

• No

• Yes

Display This Question:

If Of the studies you were asked to join, did you consider joining any of them? = Yes

Did you qualify for any of the studies you considered?

• No

• Yes

• I am not sure

 

 

Page Break

 

The following questions ask about your opinions.

How important or unimportant is it to test medicines in people aged 65 and older before doctors prescribe them to patients? 

• Not important

• Moderately important

• Very important

 

How likely or unlikely would you be to consider joining a research study that involves taking a medicine if the study was recommended by: (Mark one for each item)

	Unlikely	Neither likely nor unlikely	Likely
Your doctor
Your pharmacist
A trusted friend or family member
A person in the study (a participant)

How likely or unlikely would you be to consider joining a research study that involves taking a medicine if you received an invitation from: (Mark one for each item)

Unlikely

Neither likely nor unlikely

Likely

A university or healthcare system
A pharmacy (for example, CVS or Walgreens)
A drug company
A lab (for example, Quest or LabCorp)
A non-profit organization focused on a specific health condition

 

 

 

I would consider joining a research study that involves taking a medicine for a health problem that: (Mark ALL that apply)

• I currently have

• I want to prevent (for example, a heart attack, stroke, or diabetes)

• Runs in my family

• Might help other people

• Might advance science and/or benefit society

• Other (write in): __________________________________________________

• I would not consider joining a research study that involves taking a medicine

• I am not sure whether or not I would join

I would consider joining a research study that involves taking a medicine to: (Mark ALL that apply)

• Get a free medicine

• Try a different treatment

• Get paid

• None of the above

Display This Question:

If I would consider joining a research study that involves taking a medicine for a health problem th... = I currently have

 Would you consider joining a research study for a condition you have if you might be assigned to a group that does not get the medicine being tested?

• No

• Yes

Display This Question:

If I would consider joining a research study that involves taking a medicine for a health problem th... = I currently have

Would you consider joining a research study for a condition you have if you might be assigned to a group that will not get the medicine being tested right away, but will get it after a delay? 

• No

• Yes

 

 

 

Which of the following might make it hard for you to join a research study that involves taking a medicine?  (Mark ALL that apply)
 

▢ Poor hearing

▢ Poor eyesight

▢ Needing to be near a bathroom

▢ Problems with walking or getting around

▢ Forgetting things or problems with memory

▢ Problems with transportation to go to in-person visits

▢ ⊗None of the above

 

 

Display This Question:

If Have you ever joined a research study or clinical trial in which you were asked to take a medicine? = No

Which of the items below might make it less likely that you would join a research study that involves taking a medicine? (Mark ALL that apply)

▢ My health conditions keep me from joining

▢ I am afraid of side effects

▢ I already take too many medicines

▢ I do not have time to join

▢ The study does not pay enough

▢ I do not want to be a guinea pig

▢ My friends and family would not want me to join

▢ I take care of somebody whom I cannot leave alone

▢ Other (Write in) ________________________________________________

▢ ⊗None of the above

 

 

Page Break

 

Display This Question:

If Have you ever joined a research study or clinical trial in which you were asked to take a medicine? = Yes

 

Which of the items below would currently prevent you from joining a research study that involves taking a medicine ? (Mark ALL that apply)

▢ My health conditions keep me from joining

▢ I am afraid of side effects

▢ I already take too many medicines

▢ I do not have time to join

▢ The study does not pay enough

▢ I do not want to be a guinea pig

▢ My friends and family would not want me to join

▢ I take care of somebody whom I cannot leave alone

▢ Other (Write in) ________________________________________________

▢ ⊗None of the above 

 

 

Page Break

 

 

If you joined a clinical trial, how hard or easy would it be to have in-person visits: (Mark one for each item)

	Very Hard	Hard	Neutral	Easy	Very Easy
In your home
At your doctor’s office
At a nearby hospital or medical center (the study will pay for parking)
At a local place such as a senior center or pharmacy
That include an overnight stay at a hospital

 

 

 

 

How hard or easy would it be for you to: (Mark one for each item)

	Very hard	Hard	Neutral	Easy	Very Easy
Travel over 1 hour each way to a research site
Connect to a video visit
Check your blood pressure at home
Wear a device that monitors your physical activity, like a watch or ring
Not eat for 8 hours before a morning blood test
Have study supplies delivered to your home

 

 

 

Page Break

 

 

If you joined a research study lasting 1 year or more, how often would you be willing to do each of the following? (Mark one for each item)

	Monthly	Every 3-4 months	Twice a year	Once a year	Not at all
Have a physical exam
Have blood tests
Collect your urine
Collect your stool
Have x-rays
Travel less than 30 minutes one-way for in-person visits
Travel 1 hour or more one-way for in-person visits

 

 

 

Page Break

 

If you joined a research study that involves taking a medicine, do you prefer having visits that are: (Mark one)

• In-person only

• By video only (for example, by telehealth or Zoom)

• By telephone only

• Both in-person and by video

• Both in-person and by telephone

Would you join a research study that involves taking a medicine if visits for the study are held: (Mark one for each item)

	Yes	No	Maybe
In-person only
By video only (for example, by telehealth or Zoom)
By telephone only
Both in-person and by video
Both in-person and by telephone

If you take part in a research study that involves taking a medicine, and a visit will take a half day including travel, should you get paid (parking is free)?

• Yes

• No

• Unsure

 

 

A few last questions about yourself!

Do you currently have access to the internet in your home?

• Yes

• No

• Unsure

 

 

 

How confident are you filling out medical forms by yourself?

• Extremely

• Quite a bit

• Somewhat

• A little bit

• Not at all

 

 

 

In general, would you say your health is:

• Excellent

• Very good

• Good

• Fair

• Poor

 

 

 

Did somebody help you fill out this survey?

• Yes

• No

 

End of Block: Survey questions

 

Start of Block: Block 7 - End of Survey

 

Thank you for your participation!

Please choose from the options below.

• $25 gift card

• I do not wish to receive a gift card.

 

 

Display This Question:

If Thank you for your participation! Please choose from the options below = $25 gift card

 

Please enter your email address to receive your gift card. Gift cards may take 6-8 weeks for delivery.

________________________________________________________________

 

 

 

Would you like to be contacted for future studies?

• Yes

• No

 

 

Page Break

 

 

 

End of Block: Block 7 - End of Survey