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Required format:

bHVbZBVJzH32z4aV7csajkT4ruceo9jtXjJv5ttQ8RWH4KEMDTeTo5D6QvFoLD

Participant Recruitment Request

Returning?

A A A

Thank you for your interest in ACTNOW now. Please remember that use of the ACTNOW resources for the purpose of recruitment requires that study protocols name ACTNOW as a source of potential volunteers. If you need ACTNOW boilerplate protocol language or if you have any questions about this form, please reach out to ACTNOW Study Staff

To request participant lists from the ACTNOW repository, please enter the fields below and submit this form.

Date of Request

* must provide value

D-M-Y

Principal Investigator Information: * all fields required

PI First Name
PI Last Name
PI Email
PI Telephone

Are you the primary study contact for the requesting project?

* must provide value

Yes

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Are you the PI?

Yes

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Study primary contact information (other than PI): * all fields required

Primary contact first name
Primary contact last name
Primary contact email
Primary contact phone number

Project Title

* must provide value

Describe your project and its aims:

* must provide value

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Please provide a copy of your protocol.

ACTNOW should be explicitly mentioned as a recruitment resource in your protocol prior to requesting subjects.

Upload file

Is this a funded project?

* must provide value

Yes (specify funder(s))

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When do you need the data from this request?

D-M-Y H:M

What project type is this for?

* must provide value

Industry Clinical Trial

Non-industry Clinical Trial

Research: Exploratory

Longitudinal Non-Clinical Trial Research

Other (specify)

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Other use specify

Please let the inclusion criteria of your project:

(the inclusion criteria from your protocol required to participate in the requesting study)

* must provide value

Age (specify age range)

APOE4 carrier

Dementia Diagnosis (select all that apply)

Family history of dementia

Has a study partner

Is a caregiver

Known elevated brain amyloid determined by previous PET or CSF teseting

Racial designation (select all that apply)

Rural status

Veteran Status

Willing to do blood draw

Willing to do imaging

Willing to travel to OHSU

Other (specify)

What are the exclusion criteria for this study:

(the exclusion criteria from your protocol which will immediately remove a volunteer from eligibility in the requesting study)

* must provide value

Current drug use

Hormone levels

Medical Condition

Medication (brief list)

Obesity

Pacemaker

Recent history of alcoholism

Recent history of cancer (other than benign skin cancers)

Recent history of stroke

Recent history of TIA

Severe Mental Illness/Major Depression/Suicidal Ideation

Smoker

Unable and willing to have imagine

Other (specify)

Please list any notes or clarifications about your request for ACTNOW subjects:

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