The code block below illustrates how one might use # and // as comments in your logic and calculations.

# Text can be put here to explain what the logic/calculation does and why.
if ([field1] = '1' and [field2] > 7,

	// This comment can explain what the next line does.
	[score] * [factor],

	// Return '0' if the condition is False.
	0
)

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Required format:

KU Alzheimer's Disease Center Study Participation Survey (Estudio del centro de la enfermedad de Alzheimer de KU Encuesta de participación)

Please complete the information below to be considered for our programs and research.

Complete la información a continuación para ser considerado para nuestros programas e investigaciones.

En Español?

Yes

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Apreciamos su interés en aprender más sobre los estudios y servicios que ofrecemos en el Centro de la Enfermedad del Alzheimer (ADRC, por sus siglas en inglés) de KU. Usaremos la información en este consentimiento para entender qué estudios y servicios son más apropiados para usted. También usamos esta información para promover la participación en nuestras investigaciones. Es completamente voluntario para usted responder a estas preguntas y decidir si quiere ser contactado por el ADRC para participar en futuros estudios.

Almacenaremos su información en una base de datos segura, que será compartida con otros investigadores que estudian el envejecimiento del cerebro y demencias. Haremos nuestro mejor esfuerzo para proteger su privacidad de información. Es posible que la información compartida fuera de KUMC sea revelada por terceros, pero el riesgo de que esto suceda es bajo, gracias a los pasos que tomamos para proteger su información. Los cuidados y servicios que KUMC le ofrece u ofrecerá a usted, o a la persona por la que usted está llamando, NO se verán afectados si usted decide no proveer esta información.

Tendremos permiso para contactarlo hasta que usted decida no seguir involucrado en nuestros estudios; simplemente llame a nuestra oficina de investigación a este número: 913-588-0555 (elija la opción 1), o envíenos un email a KUADRC@kumc.edu y pregunte por el Director de Reclutamiento (Recruitment Director). Si decide terminar su involucramiento con nosotros, haremos una nota en nuestra base de datos, y no volveremos a contactarle. Puede llamar a nuestra oficina de investigación si tiene alguna duda.

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

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We appreciate your interest in learning more about the studies and services we have at the University of Kansas Alzheimer's Disease Research Center. The information you provide here is collected as part of the research process so that we can best match you to the services and studies at the Center. We also use this information to learn about how to promote participation in research. The choice to answer these questions, and be contacted for future ADRC opportunities, is entirely up to you.

We will store your information in a secure database and give your data to other researchers who are studying brain aging and dementia. We will do our best to protect the privacy of your information. It is possible that information shared outside KUMC might be released by others but our steps to protect your information lessens this risk. If you choose not to submit information, it will have NO effect on the care or services you or you the person you are calling for receive at KUMC.

The permission to contact you will stay in effect until you choose to stop your involvement. This can be done at any time by calling or emailing our research office. The phone number and address are: 913-588-0555 (Choose option 1) or KUADRC@kumc.edu and ask for the Recruitment Director. If you cancel permission, we will make the change in our records, and no longer contact you. You may use this number for any other questions you have.

Please click the "TODAY" button to enter today's date automatically.

M-D-Y

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

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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

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May we call you [the person referring] about future studies?

* must provide value

Yes

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POTENTIAL PARTICIPANT ACKNOWLEDGEMENT
(Only for individuals in which the caregiver is referring on their behalf):
May we keep on file the information you and your care partner 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

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POTENTIAL PARTICIPANT ACKNOWLEDGEMENT
(Only for individuals in which the caregiver is referring on their behalf):
May we call you, and your care partner, about future studies?

* must provide value

Yes

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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

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Potential Participant First Name

* must provide value

Potential Participant Middle Initial

Potential Participant Last Name

* must provide value

Potential Participant Street Address

Potential Participant City

Potential Participant State

Potential Participant Zip Code

Does the Potential Participant live in a nursing home, or memory care facility?

Yes

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Potential Participant Preferred Phone Number

Potential Participant Alternate Phone Number

Potential Participant E-mail Address

Potential Participant Date of Birth

M-D-Y

Potential Participant Age:

View equation

Potential Participant Gender

What is the potential participant's work status?

Is the potential participant currently being evaluated for a possible memory impairment by a physician or neuropsychologist?

Yes

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Has the potential participant been diagnosed with a memory impairment by a physician?
(For example: Mild Cognitive Impairment, Alzheimer's Disease, Dementia, Lewy Body Disease, Frontotemporal Dementia, etc.)

Yes

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Point of Contact First Name

Point of Contact Last Name

Relationship to Potential Participant

If 'other', please specify the relationship:

Point of Contact Street Address

Point of Contact City

Point of Contact State

Point of Contact Zip Code

Point of Contact Primary Phone Number

Point of Contact Alternate Phone Number

Point of Contact E-mail Address

What types of research studies are you interested in?
(Check all that apply)

Exercise and Lifestyle Intervention Trials

Investigational Medicine Trials

Discovery and Innovation Trials - Studies with no medication, exercise, or nutrition plans

Other

What other type(s) of research is the potential participant interested in?

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Are you interested in our Down Syndrome studies?

Yes

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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

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Would the potential participant have difficulty attending multiple study visits? (Consider factors such as transportation, time and flexibility in schedule, and other commitments)

Yes

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Would the potential participant be opposed to receiving an investigational medication as a part of a research study?

Yes

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If yes, please describe concerns:

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Would the potential participant be opposed to completing memory testing as a part of a research study?

Yes

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If yes, please describe concerns:

Expand

Does the potential participant have difficulty with memory testing?

Yes

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If yes, please describe concerns:

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Are you a caregiver?

Yes

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Do you both reside in the same household?

Yes

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Does the potential participant have any vacation/time out-of-town planned in the upcoming year?

Yes

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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?
If you heard about us from multiple sources, choose the one that you remember most.

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

M-D-Y

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