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CONNECT Study Interest and Eligibility
Thank you for your interest in the CONNECT Study. Please fill out the Interest and Eligibility form below. If you meet the criteria we will reach out and schedule a call about your specific situation.
1.
Contact Information
Name
Company
Address
Address 2
City/Town
State/Province
AL Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
GA Georgia
GU Guam
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
MP Northern Mariana Islands
OH Ohio
OK Oklahoma
OR Oregon
PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
ZIP/Postal Code
Country
Email Address
Phone Number
2.
Estimate the racial composition of your patient/ client population by percentage.
Please enter whole numbers. Sum should total 100.
Rough estimates are acceptable.
American Indian or Alaska Native
Asian
Black or African American
Hispanic
Native Hawaiian or Other Pacific Islander
White
Two or more races
3.
Would you consider your site to be in a rural setting?
Yes
No
4.
Please indicate if you would be a Clinical Site (Inpatient) or a Community Site (Meal Provision) for the CONNECT Study.
Clinical Site
Community Site