Research Voice Sign Up Form Question Title * 1. First Name Question Title * 2. Last Name Question Title * 3. Primary Email Address Question Title * 4. Connection to CF Person with CF Parent of a person with CF Spouse of a person with CF Sibling of a person with CF Other (please specify) Question Title * 5. What is your age? 17 or younger 18-20 21-29 30-39 40-49 50-59 60 or older Question Title * 6. What types of projects are of interest to you? (select all that apply) Educating the community about research Giving input on the design and importance of studies Looking at studies from an ethical and safety perspective Sharing results of studies Transplant research Other (please specify) Question Title * 7. Briefly describe your experience with research. Question Title * 8. Have you (or your family member with CF) participated in a study? Yes No I don't know Question Title * 9. What is the highest level of education that you have completed? High school diploma Some college Associates/ technical degree Bachelor's degree Graduate degree Other (please specify) Question Title * 10. Are you willing to do a small amount of online, self-paced training to prepare you for Research Voice activities? Yes No Question Title * 11. How many hours per month would you be willing to commit to Research Voice projects? 1 hour per month 2-4 hours per month More than 4 hours per month Question Title * 12. What additional skills, qualifications, or experiences would you like to share? In some cases, input may be needed from people who would meet specific study eligibility criteria. If you feel comfortable doing so, please indicate the following: Question Title * 13. (Optional) Are you (or your family member) currently eligible for: Yes No Unsure Orkambi Orkambi Yes Orkambi No Orkambi Unsure Kalydeco Kalydeco Yes Kalydeco No Kalydeco Unsure Symdeko Symdeko Yes Symdeko No Symdeko Unsure Question Title * 14. (Optional) Based on what you have heard or read, do you have one of the mutations that could be eligible for the triple combination therapy?Note: individuals with one copy of F508del are likely to be eligible for the triple combination therapy, regardless of their second mutation. Yes No Unsure Question Title * 15. (Optional) Have you (or your family member) ever had a transplant? Yes No Done
