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.

Question Title

* 1. Contact Information

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

Question Title

* 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

Question Title

* 3. Would you consider your site to be in a rural setting?

Yes

Question Title

* 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

CONNECT Study Interest and Eligibility

Question Title

* 1. Contact Information

Question Title

* 2. Estimate the racial composition of your patient/ client population by percentage. Please enter whole numbers. Sum should total 100.Rough estimates are acceptable.

Question Title

* 3. Would you consider your site to be in a rural setting?

Question Title

* 4. Please indicate if you would be a Clinical Site (Inpatient) or a Community Site (Meal Provision) for the CONNECT Study.

* 2. Estimate the racial composition of your patient/ client population by percentage.

Please enter whole numbers. Sum should total 100.
Rough estimates are acceptable.