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Required format:

yxSG3nTHIB3DunCz6K9tYS5S5bMzutrrxzmjjj36k6cFq3YymdgcPTUnqS4PF9KLNFrC2ZNPkdfdcntUGf5vS7qGhwEP5DuZDoB37zqi

Participant Study Interest Survey

Returning?

A A A

The University of Rochester Medical Center is conducting a screening study so that we can learn more information about people interested in our studies involving children and families.

We are collecting the information in this survey so we can contact you and discuss the study, answer any questions, and determine eligibility. If you qualify for one of our current studies, we will bring you in for a visit in which we will obtain consent, possibly draw blood depending on the study we are enrolling into and obtain some medical history information. There is no cost to you and you will be compensated for the time you spend completing the research study visits.

All information collected in this survey is protected under HIPAA privacy law. Your information will never be shared, sold, or distributed in any way.

Date of Visit

Is this survey for you or a child?

* must provide value

self

child

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Answer these questions for the parent

First Name

* must provide value

Last Name

* must provide value

Street, City, State, ZIP

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Phone number

* must provide value

E-mail Address

* must provide value

Preferred method of contact

* must provide value

Phone

Text

E-mail

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Are you currently Pregnant?

* must provide value

Yes

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Do you have children?

* must provide value

Yes

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Are you interested in enrolling your children in the study?

* must provide value

Yes

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How many children do you have?

* must provide value

Relationship to the child

* must provide value

Alternate Contact Information

Name

Phone number

Relationship to child

Answer these questions for the child

CTSI Registry Subject ID

First name

* must provide value

Last name

* must provide value

Date of Birth

Age

Does child have siblings?

* must provide value

Yes

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If so, please enter the age of each sibiling

* must provide value

Expand

MRN (if known)

Ethnicity

Hispanic or Latino NOT Hispanic or Latino Unknown / Not Reported

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Race

Gender

Female

Male

FTM

MTF

Non-Binary/Gender Queer

Prefer not to answer

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You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.