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Do you consent to the collection and processing of your personal data, including information about your financial income, race and ethnicity, and your health information, including symptoms, diagnoses, and treatments? *
The purpose for the collection and processing of your personal data is to understand the population of individuals interested in clinical trial recruitment for cancer screening. Your information will be reviewed in an anonymized manner and AutoCruitment will not contact you unless you separately enroll for AutoCruitment’s clinical trial matching services.
Yes
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Age:
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Gender:
Male
Female
Non-binary
Prefer not to say
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Where are you located?
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Which racial or ethnic group(s) do you identify with?
Please select all that apply.
Capturing information on ethnic backgrounds allows us to better understand how different groups may have different needs.
American Indian or Alaskan Native
Asian
Black or African American
Hispanic Latino or Spanish
Middle Eastern or North African
Native Hawaiian or Other Pacific Islander
White
Mediterranean (Greek/Italian/Portuguese/Spanish/etc)
Another race or ethnicity
I prefer not to answer
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What is the highest level of education you have completed?
8th grade or less
Some high school
High school graduate / GED / or certificate
Some college or technical school
College graduate
Post-graduate college degree
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Which of the options below best describes your household income?
Less than $10 000
$10 000 – $29 000
$30 000 – $59 000
$60 000 – $100 000
$101 000 – $150 000
More than $150 000
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Are you a current or past smoker?
Please select one...
Yes – Current
Yes – Past
No
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On average, how many cigarettes do/did you smoke per day?
There are 20 cigarettes in a pack
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How many years have you smoked?
If less than one year, enter 1.
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Have you ever undergone testing to screen for Colorectal cancer, Lung cancer, or any other type of cancer?
Yes – Colorectal cancer
Yes – Lung cancer
Yes – Other cancer
No
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Which other types of cancer have you been screened for?
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Which of the following types of colorectal cancer test have you done?
Colonoscopy
Fecal Occult Blood Test (FOBT)
Fecal Immunochemical Test (FIT)
Blood-based or stool-based screening test (eg. Cologuard® or EpiproColon®)
CT colonography
Flexible sigmoidoscopy
I’m not sure
None of the above
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When was your last colonoscopy?
Please select one...
2009 or earlier
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
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Do you have a colonoscopy scheduled in the future?
A colonoscopy is a medical exam that uses a long, flexible camera inserted into the rectum to detect changes in the colon.
Yes
No
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When is your upcoming colonoscopy scheduled?
This week
Within the next three months
Later this year
Next year
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Why haven’t you scheduled a colonoscopy?
I am not due for one
I am planning to schedule one
I do not need a colonoscopy
Other
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Why didn't you schedule your colonoscopy?
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Do you have a lung cancer screening, using a low-dose CT scan, scheduled in the future?
A low-dose CT is a imaging test similar to an x-ray to help diagnose lung conditions.
Yes
No
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When is your upcoming low-dose CT scan scheduled?
This week
Within the next three months
Later this year
Next year
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Have you been diagnosed with any of the following medical conditions?
Inflammatory bowel disease (IBD) including Crohn’s disease or ulcerative colitis (US)
Lung cancer
Any other type of cancer other than squamous cell or basal cell skin cancer
None of the above
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Would you be interested in a cancer screening trial where you would provide blood samples and undergo a routine lung scan or colonoscopy?
Very Interested
Interested
Somewhat Interested
Not Interested
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What type of medical insurance do you currently have?
Medicare
Medicaid
Commercial/Private
None
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Would any of the following prevent you from participating?
Scheduling logistics
Travel to appointment
Colonoscopy
Cost limitation
Lack of insurance
Other
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What else would prevent you from participating?
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