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

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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.

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Required format:

ALL ALS Consortium Participant Interest Intake Form

If you wish for a member of study team to contact you about the ALL ALS consortium, please include your name and preferred contact information below:

First Name

Last Name

City of Residence

State of Residence

Zipcode

Phone number

E-mail

Are you interested in participating in ALL ALS Consortium Studies?

What is your preferred method of contact?

* must provide value

Phone

How did you hear about us?

Social Media

Online Search (Google, Bing, etc.)

Healthcare Provider

ALL ALS Website

Community event/conference

Newsletter

Webinar

Word of mouth

Other

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If other, please specify:

Questions/Comments for Study Staff

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You are being asked to be in an ALL ALS Consortium contact information database that will collect and store information about you and allow contact by the ALL ALS Consortium study team.

Your contact information will be entered into a password-protected, web-based database, which will be managed by the ALL ALS Consortium for the duration of the study. The central research team will know your identity and that you are in the contact information database. All personnel working on this database are trained on the importance of protecting your privacy. The utmost of care is used to make sure that all your information is secure.

The study staff at Massachusetts General Hospital (MGH) and Barrow Neurological Institute(BNI) clinical coordination centers will share the records generated from this database with the ALL ALS patient navigation designees and applicable participating sites listed on the website. This information is shared so that the appropriate site staff can contact you with more information about the studies and answer any questions that you may have about ALL ALS consortium studies. The people receiving this information may not be required to protect it and your information may be redisclosed without your permission. If you do not provide permission to use your information you cannot be in the database.

We use your information in order to contact you about ALL ALS studies that may be of interest to you or receive updates about the ALL ALS consortium. You may receive periodic emails, newsletters, mailings or phone calls about the ALL ALS Consortium. You may opt out of receiving this communication at any time.
Your decision to be in this database is voluntary. A copy of this information and consent will be provided to you by email, or is available on the website

TO ACCEPT TERMS PLEASE SELECT "YES, I AGREE"

Yes

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Was potential participant contacted?

Yes

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Date Contacted

D-M-Y

Was the potential participant referred to a site?

Yes

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Which site was the potential participant referred to?

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.