Yes
Please select "Yes" here if this record has been created for the purposes of assigning a RED ID and affiliating the record with studies ONLY. No PHI should be entered in this record unless the participant is explicitly consented into RED. You may only enter initials, race, ethnicity, memory status, and screening/enrollment information.
Yes
Please click the "TODAY" button to enter today's date automatically.
Today M-D-Y MM-DD-YYYY
Would you like yourself or a loved one to be considered for clinical research at the KU Alzheimer's Disease Research Center?
Self
Loved One
May we keep on file the information you have provided? We may use this information to identify appropriate studies, present or future, conducted by the KU ADRC or by researchers who have received our permission to use this data.
* must provide value
Yes
No
May we call you [the person referring] about future studies?
* must provide value
Yes
No
POTENTIAL PARTICIPANT ACKNOWLEDGEMENT
* must provide value
Yes
No
POTENTIAL PARTICIPANT ACKNOWLEDGEMENT
* must provide value
Yes
No
Who is the primary person to contact for future opportunities? (This is the contact information that should be used in the future.)
Potential Participant
Person Making Referral
Potential Participant First Name
* must provide value
Potential Participant Middle Initial
Just the initial (not the whole name); do not include the period. You may leave blank if they do not have a middle initial.
Potential Participant Last Name
* must provide value
Potential Participant Street Address
Potential Participant City
Potential Participant State
2-Letter Abbreviation
Potential Participant Zip Code
Does the Potential Participant live in a nursing home, or memory care facility?
Yes
Potential Participant Preferred Phone Number
Include Area Code (000-000-0000)
Potential Participant Alternate Phone Number
Include Area Code (000-000-0000)
Potential Participant E-mail Address
Potential Participant Date of Birth
Today M-D-Y MM-DD-YYYY
Potential Participant Age:
View equation Potential Participant Gender
Female Male Non-binary Prefer not to respond
What is the potential participant's work status?
Retired or not working Part Time Work Full Time Work
Is the potential participant currently being evaluated for a possible memory impairment by a physician or neuropsychologist?
Yes
No
Has the potential participant been diagnosed with a memory impairment by a physician?
Yes
No
Point of Contact First Name
Include title as needed, e.g. Mrs./Mr./Ms.
Point of Contact Last Name
Relationship to Potential Participant
Son Daughter Wife Husband Friend Other
If 'other', please specify the relationship:
Point of Contact Street Address
2-Letter Abbreviation
Point of Contact Zip Code
Point of Contact Primary Phone Number
Include Area Code (000-000-0000)
Point of Contact Alternate Phone Number
Include Area Code (000-000-0000)
Point of Contact E-mail Address
What types of research studies are you interested in?
What other type(s) of research is the potential participant interested in?
Are you interested in our Down Syndrome studies?
Yes
No
Are you interested in a specific research study? If yes, please list the name of the study
Does the potential participant have someone that can act as a study partner and occasionally attend study visits to report on the participant's memory?
Yes
No
Would the potential participant have difficulty attending multiple study visits? (Consider factors such as transportation, time and flexibility in schedule, and other commitments)
Yes
No
Would the potential participant be opposed to receiving an investigational medication as a part of a research study?
Yes
No
If yes, please describe concerns:
Would the potential participant be opposed to completing memory testing as a part of a research study?
Yes
No
If yes, please describe concerns:
Does the potential participant have difficulty with memory testing?
Yes
No
If yes, please describe concerns:
Yes
No
Do you both reside in the same household?
Yes
No
Does the potential participant have any vacation/time out-of-town planned in the upcoming year?
Yes
No
Please list number of weeks the potential participant will likely be out of town:
How did you hear about the KU Alzheimer's Disease Research Center?
Brochure, Flyer, or Poster Family or Friend Health Care Professional (MD, RN, Social Worker, etc.) Mail/Letter or Email MyAlliance Newspaper, Magazine or Podcast Public Presentation/Event (in person) Social Media (Facebook, Twitter, etc.) TV or Radio Webinar Website/Internet
Nos gustaría obtener su permiso para almacenar la información que nos ha dado en una base de datos segura. Es posible que usemos esta información para identificar estudios, ahora y en el futuro, realizados por KU ADC o por investigadores que tienen permitido utilizar nuestros datos.
Most recent date contact information updated
Today M-D-Y MM-DD-YYYY
