User journey study: Research study interest form

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Thank you for wanting to share your story! Your participation in this study will help make a positive impact on the lives of people across India.

If you meet the criteria to participate, someone from our team will contact you at the phone or email address you provide in the form to schedule an interview.

The interview will take about 90 minutes and will be conducted by phone or Zoom. No one will be able to link your name to any information you share with us or to your participation in this study.

You will receive an Amazon gift card worth Rs 700 after finishing the interview!

Want to know more about the study? It’s conducted by researchers at Ibis Reproductive Health, Asia Safe Abortion Partnership (ASAP), and University of California San Francisco (UCSF). Together, we work to make the world a place where everyone has the power and resources necessary to enjoy the human right to a pleasurable, safe, and healthy reproductive life.

What is your age? *

Which of the following languages do you speak? *

English

Hindi

None of the above

Other:

Required

Who terminated the pregnancy: was it you, your partner, or your family member? *

My partner

My family member

None of the above

Which year was the termination of pregnancy? *

Did you or your partner/family member use pills to terminate the pregnancy? *

Yes

Unsure

Other:

How did you or your partner/family member obtain the pills? *

We or someone we know bought them at a pharmacy *with* a prescription

We or someone we know bought them at a pharmacy *without* a prescription

We or someone we know obtained them at a clinic

Unsure

Other:

What State do you currently live in? *

What District do you live in? *

Is this district:

Urban

Rural

Peri-urban

Other:

Clear selection

Please provide a valid email address that the study team can use to contact you about participation in the study (or write NA if you prefer to be contacted by phone): *

Please provide a phone number that the study team can use to contact you about participation in the study (or write NA if you prefer to be contacted via email): *

Please indicate if there are certain times that you would prefer the study team to contact you:

Anytime is fine

I have preferred times

Clear selection

My preferred times to be contacted are:

Please provide a preferred name:

Submit

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