Chinese (Simplified Han)
Chinese (Traditional Han)
Join Alzheimer’s research study
Please answer all the questions to join this research study. Your answers are kept confidential and will not be shared with anyone except the research team.
1. Are you answering for yourself or on behalf of someone else?
I’m answering for myself
I’m answering for someone else
1.1 Your name
1.2 Your relationship with the participant:
1.3 Your Email
Please consider all mentions of “you” and “your” to refer to the participant in all questions that follow from now on.
4. How did you hear about this study? Please provide details such as in which language, where and when if possible.
Community Service Center.
Conference, Community Forum, seminar or Workshop.
Email through a listserv.
At a health care provider’s office.
How did you hear about this study? Please provide details such as in which language, where and when if possible.
5. Do you live in the United States or Canada?
6. Do you have any of the following ancestral backgrounds? (select all that apply)
7. Is your mother Chinese, Korean or Vietnamese? (select all that apply)
8. Is your father Chinese, Korean or Vietnamese? (select all that apply)
9. Are you 60 years or older?
10. Do you have memory problems or other changes in how your brain works?
If Yes, please specify.
10.1 Are you diagnosed with Alzheimer’s disease?
11. Are you willing to answer questions about your personal history and have your memory tested?
12. Would you be willing to give at least one blood or saliva sample for genetic testing, although your results will not be reported back to you?
Thank you for completing the questionnaire. You appear to pass all study criteria. As a last step, the research team would like to speak with you on the phone. You will get the opportunity to learn more about the study and ask questions before deciding to join.
Preferred time(s) to be contacted:
Wayturn contact email
Should be Empty: