Survey Start Time Now M-D-Y H:M
CS MRN
Patient Provided CS Link First Name ______ Middle Name ______ Last Name ______ Phone ______ Date of Birth ______
Yes
Now M-D-Y H:M
NAME OF STUDY: THE CORONAVIRUS RISK ASSOCIATIONS AND LONGITUDINAL EVALUATION (CORALE) STUDY CEDARS-SINAI MEDICAL CENTER STUDY00001411
IBD PRINCIPAL INVESTIGATOR: GIL MELMED, MD MS SUSAN CHENG, MD, MPH, MMSC 310-423-5643
This research study is sponsored by CEDARS-SINAI MEDICAL CENTER, which reimburses only Cedars-Sinai for the costs associated with running the study and does not provide additional compensation to Cedars-Sinai or the Principal Investigator for their participation in the study.
Pg 13/14 Intentionally Blank I am at least 18 years of age at the time I am agreeing to participate in this study?
* must provide value
True
False
This coh ort is designed for inflammatory bowel disease (IBD) patients only. If you are interested in participating in the CORALE research program and have NEVER been diagnosed with either Crohn's disease, ulverative colitis or indeterminate colitis please email ibdreasearch@cshs.org so we can ensure you are assigned to the correct cohort.
Has a doctor EVER told you that YOU have Inflammatory Bowel Disease (IBD) ?
* must provide value
Yes, Crohn's disease
Yes, ulcerative colitis
Yes, indeterminate colitis
No, I don't have IBD
I hereby agree to participate in the research study described to me during the informed consent process and described in this informed consent form. A copy of this form will be sent to the email address provided.* must provide value
Yes, I agree to participate
No, I do not wish to participate
Authorization for Use and Disclosure of Identifiable Health Information (Research): I hereby agree that my identifiable health information may be used and/or disclosed in accordance with this "Authorization for Use and Disclosure of Identifiable Health Information (Research)" form attached as Appendix to this form.
* must provide value
Yes, I agree my information may be used for the purposes of this study
No, I do not wish to participate
First Name* must provide value
Middle Name or Initial
Last Name* must provide value
Date of Birth * must provide value
M-D-Y MM-DD-YYYY
Preferred Email* must provide value
Enter your preferred email again* must provide value
EMAILS DO NOT MATCH PLEASE VERIFY Alternative Email
Address* must provide value
City* must provide value
State* must provide value
AL AK AS AZ AR CA CO CT DE DC FL GA GU HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PA PR RI SC SD TN TX UT VT VA VI WA WV WI WY
Zipcode* must provide value
Preferred Phone No.* must provide value
(xxx)-xxx-xxxx
Select one:* must provide value
Cell
Home
Alternative Phone No.
Preferred method for us to contact you: Email
Phone call
Text message
Postal mail
All of the above
check all that apply
Do you receive your IBD care at any of the following institutions? Atlanta Gastroenterology Associates
Morehouse School of Medicine
Other
Do you receive your IBD care at any of the following institutions? Baylor College of Medicine
UT Southwestern
Other
Do you receive your IBD care at any of the following institutions? Beth Israel Deaconess
Other
Do you receive your IBD care at any of the following institutions? Capitol Digestive Care, D.C.
Medstar Georgetown
Johns Hopkins IBD Center
Other
Do you receive your IBD care at any of the following institutions? Johns Hopkins IBD Center
Other
Do you receive your IBD care at any of the following institutions? Mayo Clinic
Other
Do you receive your IBD care at any of the following institutions? The Oregon Clinic
Oregon Health Sciences University
Other
Do you receive your IBD care at any of the following institutions? Saratoga Schenectady Gastroenterology
Stony Brook University Hospital
Other
Do you receive your IBD care at any of the following institutions? Attune Health
Cedars-Sinai
Center for Rheumatology
Hoag Memorial
Palo Alto Medical Foundation
University of California, Irvine
University of California, San Diego
University of Southern California (Keck Hospital)
Other
Do you receive your IBD care at any of the following institutions? University of Utah
Other
Do you receive your IBD care at any of the following institutions? University of Washington
Other
Do you receive your IBD care at any of the following institutions? Virginia Mason
Other
Do you receive your IBD care at any of the following institutions? Dartmouth-Hitchcock Medical Center
Other
Do you receive your IBD care at any of the following institutions? Gastro One
Other
Do you receive your IBD care at any of the following institutions? University of Colorado Medical Campus
Other
Do you receive your IBD care at any of the following institutions? Spectrum Health
Henry Ford Medical Group
Other
Do you receive your IBD care at any of the following institutions? University of Mississippi Medical Center
Other
What is the name of the primary clinic or provider who provides your IBD care?
Participant Signature* must provide value
Participant Date signed * must provide value
Today M-D-Y
The above is in association with Study: THE CORONAVIRUS RISK ASSOCIATIONS AND LONGITUDINAL EVALUATION (CORALE) STUDY
EMAILS DO NOT MATCH. PLEASE VERIFY BEFORE PROCEEDING
When you complete this form, you will receive a confirmation email to: ______
--- OFFICE USE ONLY --- Signature By the Investigator
Name of study staff obtaining consent
Study Staff Signature
Date signed by Study Staff Today D-M-Y
Withdrawl Has the participant requested withdrawal from the study? Yes
No
If yes, why?
Name of study staff who completed the participant's request
Date withdrawn Today M-D-Y
Patient Provided CS Link Email ______ Address ______ City ______ State ______ Zip ______
CS First Name
cs middle name
CS Last Name
CS Email
CS address
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