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:

Personal Network Survey for Clinical Research

This survey is for demonstration purposes only. Please do not save any information. Please do not enter any personal or clinical information. All data will be deleted promptly from the survey and may not be accessible.

Loading...

Welcome to the Personal Network Survey!

This Personal Network Survey is a scientific approach to understand how your social ties influence achievement of your health-related goals.

We estimate that this survey will take about 15-20 minutes. The preferred platform for taking this survey is a desktop computer, laptop computer, or a tablet with external keyboard. You may also use a smartphone, though it may be more difficult for you to enter your answers.

Please carefully follow the instructions, particularly at the beginning of this survey, as your answers impact the remaining questions.

Your Age

Gender

Male

Female

Other

Race (Select all that apply)

Black or African American

White

American Indian/Alaska Native

Asian

Native Hawaiian or Other Pacific Islander

Other

Skip question

Ethnicity

Hispanic or Latino

NOT Hispanic or Latino

Unknown

Skip question

Education level

Your Zip Code

Employment Status

Current Occupation

What is your approximate household net worth?

Marital Status

Do you live alone?

Yes

No

How many people are in your household?

Who is in your Personal Network?

In order to understand your personal network and the different ways in which people are important to you and support you, we are now going to help you create a master list of people by asking you who falls into these three categories:

Who do you discuss important personal matters with?
Who do you often socialize with?
Who provides you support for your health needs?

We are only interested in people who fall into one of those three categories, and we'd like you to think only about your current network of people in your life who are age 18 or older.

Please only use first names, nicknames, or initials - DO NOT USE FULL NAMES. If two people have the same first name, then add a last initial. You can enter any identifier you'd like in place of a name - all that matters is that you know the person you mean, as the "names" you enter will be used later in the survey.

Who do you discuss personal matters with?

Name 1

Name 2

Name 3

Name 4

Name 5

More names, separated by commas (if needed):

Expand

Name 1

Name 2

Name 3

Name 4

Name 5

More names, separated by commas (if needed):

Expand

Name 1

Name 2

Name 3

Name 4

Name 5

More names, separated by commas (if needed):

Expand

Finalizing your list of people:

Now, we are going to create a master list from the names you provided above, and you will remove duplicates and blanks. Know that we are only going to use the first 5 names you entered from each section above - that's okay!

Please read these instructions carefully:

Click the "Keep" button next to the first time a person is named in the list. If you do not click "Keep," then the name will be removed.
If a person shows up in the list more than once, only choose "Keep" once.
All blanks and duplicates should be left as "Remove".

Keep

Remove

______

* must provide value

______

* must provide value

______

* must provide value

______

* must provide value

______

* must provide value

______

* must provide value

______

* must provide value

______

* must provide value

______

* must provide value

______

* must provide value

______

* must provide value

______

* must provide value

______

* must provide value

______

* must provide value

______

* must provide value

Number Filled in First 10 Slots

View equation

Total number of social contacts

View equation

Relationship Description

We are now going to focus on the relationships in your social network. If you notice some names missing, that is okay - we are only using the first 10 from your master list.

Below should be a list of unique names without blanks. If there are missing names from the first 10, duplicate names, or blanks, please STOP and go back to the previous section where you made your master list by choosing "Keep" for certain names. Please review the instructions for that section, and adjust your "Keep" or "Remove" choices as needed. We are interested in how close you feel to each person below.

Compared to everyone you've listed, how close do you feel to each person?

______

* must provide value

especially close

not especially close

______

* must provide value

especially close

not especially close

______

* must provide value

especially close

not especially close

______

* must provide value

especially close

not especially close

______

* must provide value

especially close

not especially close

______

* must provide value

especially close

not especially close

______

* must provide value

especially close

not especially close

______

* must provide value

especially close

not especially close

______

* must provide value

especially close

not especially close

______

* must provide value

especially close

not especially close

______

* must provide value

especially close

not especially close

______

* must provide value

especially close

not especially close

______

* must provide value

especially close

not especially close

______

* must provide value

especially close

not especially close

______

* must provide value

especially close

not especially close

You've just finished the hardest part of the survey, and you're 25% done. Keep going!

We will now focus on the relationship between each pair of people you mentioned. For example, we will ask about ______ and ______. For each pair, we will ask whether they are total strangers, in-between, or especially close. Here is what we mean by each term:

Total strangers: The two people wouldn't recognize one another if they met on the street.

In-between: Relationships in the middle of total strangers and especially close. Typically, these people are casual acquaintances.

Especially close: The two people are as close or closer to each other than they are to you.

Take your time. This can be difficult.

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

Is ______ a total stranger, especially close, or in-between with ______?

* must provide value

stranger

in-between

especially close

You've completed 50% of the survey - great job!

Supports me most often

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

What kind of support does each person give you? (Select all that apply)

Types of Support

Emotional Support: This would be someone who you turn to when you need help managing personal situations, and share feelings of happiness or sadness.

Life Advice: This would be someone who gives you advice on life decisions such as employment or places to live.

Financial Support: This would be someone who gives you advice or provides direct help with your daily or overall finances.

Physical or Health Support: This would be someone who gives you advice on or provides direct help with medications/supplements, choosing doctors or getting to appointments, mental health resources, managing health insurance, or physical assistance around your household.

Camaraderie: This would be someone who provides support through understanding important experiences that you have had together.

Emotional support

Life advice

Financial support

Physical or Health
support

Camaraderie

None

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

Male

Female

Other

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

Yes

No

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

Black or African American

White

American Indian/Alaska Native

Asian

Native Hawaiian or Other Pacific Islander

Other

Don't know

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

Some high school or less

High school grad

Some college

Associate degree

Bachelor's degree

Graduate degree

Don't know

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

Daily

Weekly

Monthly

Less often

Don't know

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______

______

______

______

______

______

______

______

______

______

______

______

______

______

Less than three

Three to six

More than six

Don't know

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

Spouse

Family

Friend

Advisor

Co - worker

Other

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

You're almost done with the survey - only a few more questions!

Have you cut back on heavy drinking of alcohol in the past 3 months?

Yes

No

I do not drink heavily

Have you cut back on smoking in the past 3 months?

Yes

No

I do not smoke

Have you exercised at least 3-4 times a week over the past 3 months?

Yes

No

Did you eat a healthy diet regularly over the past 3 months?

Yes

No

In which areas do you feel you experience more health problems than the average person? (Select all that apply)

General Health

Pain

Cognitive/Mental Health

Cardiac

No Health Problems

Yes

No

Does not drink heavily

Don't know

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

Yes

No

Does not smoke

Don't know

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

Yes

No

Don't know

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

Yes

No

Don't know

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

General Health

Pain

Cognitive/Mental Health

Cardiac

No Health Problems

Don't know

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

Same house

1-5 miles

6-15 miles

16-50 miles

50+ miles

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

Did you encounter any technical difficulties during this survey?

Yes

No

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.