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Batten-1 Phase 3 Clinical Trial Interest
We are interested in gathering information to help inform clinical trial recruitment. Your feedback is greatly appreciated. Please note that all responses to this survey are anonymous.
1.
Patient Information:
Age:
Gender:
Date of Diagnosis:
City of Residence:
State of Residence:
Country of Residence:
2.
Additional Patient Information (If more than 1):
Age:
Gender:
Date of Diagnosis:
City of Residence:
State of Residence:
Country of Residence:
3.
On-site assessments will be conducted every 6 months. Are you (patient and caregiver) willing to participate in the on-site visits ?
Yes
No
If "No," why not?
4.
Some site visits may require an overnight stay (or 2 in the case of travel). Are overnight stays acceptable?
Yes
No
If "No," why not?
5.
Travel expenses will be covered by the sponsor. How far are you willing to travel to participate in on-site visits?
Less than 2 hours
Between 2 & 6 hours
Over 6 hours, but within same day
Overnight travel
In case of limits, what would be the main reason (patient too weak/tired, lack of availability of caregiver, other)?
6.
What forms of transportation are acceptable?
Car
Train
Plane
Other Comments
7.
Are you willing to travel to a different country?
Yes
No
If "No," why not?
8.
Additional Comments:
