NBCA Blood Clot Patient Experience Survey

Instructions: A medical device company is designing a clinical study to look at the safety and efficacy of a medical device to treat patients with venous blood clots. To ensure that the study meets the needs of patients, the company is partnering with the National Blood Clot Alliance (NBCA) to gather feedback. The investigators of this survey do not anticipate any risks involved with your choice to participate. Your participation in this survey is voluntary and you may exit at any point.

This survey will ask questions about your background (demographics), experience with venous blood clots, feelings concerning clinical studies, and willingness to participate in further discussions on clinical study design. If you are interested and willing to participate in further discussions, you will be asked to share your email address and phone number to allow NBCA to contact you. Your answers will provide feedback on the design of a clinical study that provides a meaningful and positive experience to participants.

You must be 18 years or older to participate in this survey. Your participation is voluntary, and your responses will be kept anonymous; any personal information that could identify you will be removed or changed before your responses are shared with other researchers. The survey will take about 15-25 minutes to complete.

In appreciation of your time, all participants who complete the survey will have the option to enter their email into a drawing for a $250 Amazon gift card and an NBCA swag bag. Your entry for the gift card and swag bag will occur on a different web page and is in no way connected to your responses.

If you have any questions regarding the purpose of this study, or the use of the data, you may contact the investigators at 703-935-8845 or info@stoptheclot.org.

Question Title

* 1. Have you ever been treated for a blood clot in your vein, also called a venous blood clot? It may be a deep vein thrombosis (blood clot that forms in your arm or leg) or pulmonary embolism (blood clot that breaks off and travels to your lungs).

Yes – if yes, please proceed with completing this survey

No – if no, you do not need to complete the survey - thank you for your interest!

Question Title

* 2. What is your age range?

18-20 years

21-29 years

30-39 years

40-49 years

50-59 years

60-69 years

70-79 years

80-89 years

90 years and above

Question Title

* 3. How would you describe your ethnicity?

Hispanic or Latino

Not Hispanic or Latino

I don’t know

I prefer not to answer

Question Title

* 4. How would you describe your race?

American Indian or Alaska Native

Asian or Asian American (select all that apply)

Asian Indian (India, Pakistan, Bangladesh, Sri Lanka, etc.)

Chinese

Filipino

Japanese

Korean

Vietnamese

Other Asian

Black

African American

Native Hawaiian or other Pacific Islander

White

Another race

I don't know

I prefer not to answer

Question Title

* 5. Were either of your parents born outside the United States?

Yes

I don’t know

I prefer not to answer

Question Title

* 6. What sex were you assigned at birth, on your original birth certificate?

Male

Female

I don’t know

I prefer not to answer

Question Title

* 7. How do you identify your gender?

Male

Female

Transgender male

Transgender female

Nonbinary

Other

I don’t know

I prefer not to answer

Question Title

* 8. Which of the following best represents how you think of yourself?

Lesbian or gay

Straight, that is, not gay or lesbian

Bisexual

I don’t know

I prefer not to answer