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INSTANT Study at KU Medical Center Initial Eligibility Questionnaire

INSTANT Study at KU Medical Center

Initial Eligibility Questionnaire

Study Purpose

The goal of the INSTANT study is to understand how different types of daily stressors may influence people's ability to be active and sleep well.

Study Qualifications

To qualify for this research study, you must:

Be enrolled (or plan to enroll within 3 months) in a community-based weight loss program.
Be able to attend in-person visits at the University of Kansas Medical Center in Kansas City.
Be at least 18 years old.
Own a smartphone and be willing to download a mobile application to receive text messages.

There are additional study specific qualifications that will be discussed with a staff member.

Study Duration

This study will last for 26-weeks (about 6-months), with 4 in-person visits total.

Compensation

Participants can earn up to $300 for completing the study.

You may also receive a waived or reduced initiation fee from the KUMC weight loss program for enrolling in this study.

Community-Based Weight Loss Programs

Since participation in a community-based weight loss program is a study qualification we are offering a reduced price at the KUMC weight loss program. We are offering a $362.00 reduction on the program fee, so INSTANT participants pay $97.00 for the entire 6-month program.

More information on the KUMC weight loss program can be found here:

· KUMC 5-3-2-1 Flyer: LINK
· KU Weight Management Program Options: LINK

Another qualifying program is the Johnson County Diabetes Prevention Program. Information about this program can be found this LINK.

Study Contact

If you have any questions or would like more information, please contact us at: instant@kumc.edu

Please provide the following details so we can contact you for more information on the study.

To participate in the study, we will need some more information from you.

This information will be used for scheduling the initial visit.

First Name:

* must provide value

Last Name:

* must provide value

Email Address:

* must provide value

Phone Number (include area code).

This is the number we will contact for scheduling and questions related to the study.

Study staff may send text messages to this line.

* must provide value

Sex

* must provide value

Male

Female

Prefer not to answer

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Race (select all that apply)

* must provide value

White

Black or African American

American Indian or Alaskan Native

Asian - Asian Indian

Asian - Chinese

Asian - Filipino

Asian - Japanese

Asian - Korean

Asian - Vietnamese

Asian - Other

Pacific Islander - Native Hawaiian

Pacific Islander - Guamanian or Chamorro

Pacific Islander - Samoan

Pacific Islander - Other

Other

Don't Know

Ethnicity

* must provide value

Not of Hispanic, Latino/a, or Spanish origin

Hispanic Mexican, Mexican American, or Chicano/a

Hispanic Puerto Rican

Hispanic Cuban

Other Hispanic, Latino/a, or Spanish origin

Date of Birth

For this study, you must be 18 years old or older.

* must provide value

M-D-Y

Participant Age at Web Screening

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(One selection allowed per column)

Phone Call

Text Message

Preferred

* must provide value

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Secondary

* must provide value

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Tertiary

* must provide value

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Height:

Feet:

Inches:

Inches Total:

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Most recent weight (lbs.):

* must provide value

BMI:

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Participation in a community-based weight loss program is a study qualification. We are interested in learning more about your plans to enroll in a qualifying program, allowing you to be eligible for this study.

Are you currently enrolled in a community-based weight loss program (e.g., Diabetes Prevention Program, 5321 program)?

* must provide value

Yes

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If yes, when was your first visit related to this program? Or when is it scheduled to occur?

For the 5-3-2-1 program, this is your ramp up meeting.

This date would not include any informational sessions you attended ahead of time, only the first visit that counted towards the program.

* must provide value

M-D-Y

If no, do you plan on enrolling in a community-based weight loss program within the next 3 months?

* must provide value

Yes

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What is the name of the community-based program you are enrolled in, or plan to enroll in?

* must provide value

When do you start this program?

Are you fluent in reading, writing, and speaking in the English Language?

* must provide value

Yes

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Is there currently a family member enrolled in the INSTANT study, or has a family member previously participated in the INSTANT study?

* must provide value

Yes

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Do you own a personal smartphone?

* must provide value

Yes

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If you are eligible for the study, you will be asked to download the study app (RealLife Exp) on your mobile device and use the app for the duration of the study. We will NOT be providing phones.

The app is free, but you will be responsible for any data costs you may have with your personal data plan.

The study team will provide you a generic email address to use to create your RealLife Exp account. You will use this email address to log into the app.

Are you comfortable downloading a mobile application to your personal smartphone or similar device?

* must provide value

Yes

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English

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Own Phone

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App

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If all 4

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If all 6: app, phone, English, age, and BMI

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How did you hear about the study?

* must provide value

Referred by a current/past participant of this study

Past participant in other KUMC study

Flyer

Local community event

Friend

Social media

Other

SKIP

Other source:

* must provide value

May we save your contact information to invite you to future research studies within the Division of Physical Activity and Weight Management?

* must provide value

Yes

SKIP

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Employee Email

Date survey completed:

M-D-Y H:M:S

INST

INSTANT ID:

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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.