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
)

Working …

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

User Completing Form

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UH Research Participant Database

Please complete the following information if you would like to be included in the University Hospitals Research Participant Database.

You can choose if you would like to be contacted about participating in clinical research studies and also if you would like to receive communication and updates from the UH Clinical Research Center.

Your personal information is kept confidential and participation in clinical research is always voluntary.

Want to learn more about research studies and clinical trials? Visit UHhospitals.org/Research

Date of Survey

M-D-Y

Who is completing this survey?

Self

Parent, Guardian, or Caretaker

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Relationship

First Name of Person Completing Form

Last Name of Person Completing Form

Referral Source

* must provide value

Radio Ad

TV Ad

Print Ad

Flyer

ResearchMatch

ClinicalTrials.gov

UH Clinical Trials Finder

Website

Facebook / Instagram/Twitter

Case Daily

Physician Referral

Friend/Family

Community Outreach Event

aEMR/Research IT

Unknown

Previously Participated in Research

UH Clinical Research Kiosk

Other

Recruitment Email/Letter

1-833-78TRIAL (1-833 788-7425)

COVID-19 Research Recruitment Video

Recommendation from another Research Participant

Referral Source

* must provide value

Location of Event/Referral Source

* must provide value

Date of Event

M-D-Y

Event

Explain Other Referral

* must provide value

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Name of Physician

First Name

* must provide value

Last Name

* must provide value

Date of Birth

* must provide value

M-D-Y

Email Address

* must provide value

Phone Number

Types of communications you wish to receive:
(select all that apply)

* must provide value

Research Study Opportunities

UH Clinical Research Newsletter (Adults)

UH Rainbow Clinical Research Newsletter (Pediatrics)

Preferred Method(s) of Contact
(select all that apply)

* must provide value

Phone Call

Text Message

Mail

Phone Number (old)

Email Address:

Street Address:

City:

State / Province:

Zip / Postal code:

Country:

Study Interest #1

* must provide value

Study Interest #1

Study Interest #2

Study Interest #3

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Study Interest #3

Study Interest #4

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Study Interest #4

Study Interest #5

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Study Interest #5

Other Study Interests/Comments

Would you be interested in participating in a study that enrolls healthy volunteers and/or control volunteers that are needed to study specific health issues?

Yes

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Would you be interested in joining the UH Clinical Research Center's Community Advisory Board?

The Clinical Research Community Advisory Board (CAB) is a group of engaged, diverse community members who want to learn more about clinical research and influence the processes of clinical trials in a way that ensures inclusivity and a positive patient experience.

Yes

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Notes

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What is your primary health care organization?

Patient's PCP Location

Gender

Male

Female

Other

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Other- Specify

Race

Caucasian/White

African American/Black

American Indian or Alaskan Native

South Asian

All Other Asian

Native Hawaiian or Other Pacific Islander

Unknown

Biracial

Other

Ethnicity

NOT Hispanic or Latino

Hispanic or Latino

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Which UH locations would you be interested in going to for research visits?

If other, please explain

2nd Location?

If other, please explain

3rd Location?

If other, please explain

Are you currently or have you ever been a UH patient?

* must provide value

Yes

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Additional Info (for CRC Only)

Patient's PCP

Does volunteer want to continue being contacted for future studies?

NO - DO NOT CONTACT

Yes

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Date of Opt-Out

M-D-Y

Patient's Status

Alive

Deceased

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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.

UH Research Participant Database

CONTACT INFORMATION

Study Interests

DEMOGRAPHICS

Additional Info (for CRC Only)

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