MiDE Participant Survey

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Required format:

SMhIivJs7x6XEKg4zfwgP3NDg6zFXZZIuRRGBxrE2RfnuTAon9fmeVMZLo3hURxYTYTnBcNQrpEYTkPMKwwsb5EGDeVTMqi5RH97a5etUtMdGG6CRrI6oLES4VY

Thank you for your interest in participating in the MiDe Study!

The MiDe study aims to better understand cancer risk for people at high risk of developing ovarian cancer. This may include those with known genetic mutations linked to increased ovarian cancer risk or relatives diagnosed with an ovary-related cancer.

If you have any questions please contact the team at MiDeStudy@DFCI.HARVARD.EDU

If you would like to participate. Please complete the items below.

Today's Date:

* must provide value

M-D-Y

First Name:

* must provide value

Last Name:

* must provide value

Date of Birth:

* must provide value

M-D-Y

Age

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Race:

Ethnicity:

Zip Code:

Email:

Primary Phone Number:

* must provide value

How did you hear about this research study:

* must provide value

Please tell us the name of your healthcare provider who referred you to this study:

* must provide value

Please list your relatives(s) who referred you, and their relation to you:

* must provide value

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Please list which organization you heard about this study from:

* must provide value

Please list which social media site(s) you heard about this study from:

* must provide value

Please list who referred you or how you were referred to this study:

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Have any of your family members enrolled in this study already?

Please note, your relative(s) may have referred you to this study. If you have already indicated this above, please select "yes" and re-list your relative(s) below).

* must provide value

Yes

I Don't Know

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Please list your relatives(s) who are enrolled in this study and their relation to you:

* must provide value

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Please select the way(s) that you would prefer to be contacted?

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Phone Call

Please select the time that you would prefer to be contacted?

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Morning (9 am - 12 pm EST)

Mid-day (12 pm - 2 pm EST)

Evening (2 pm - 5 pm EST)

internal record ID

Participant Location

DFCI

Outside location

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Participant Point Person

Ryan Buehler

Samantha Stokes

Kevin Short

Goniola Bode

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Enrollment Status

In progress

Complete

Decline

No response, could not consent

Determined to be not eligible

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Recruitment Notes

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Recruitment Tracking Checklist

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Upcoming Visit Date

M-D-Y

Upcoming Visit Time

H:M

Provider

Clinic

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.