Xavier - CCC Registration Form

COCCI Community Conversations

Xavier University - April 11, 2022 PLEASE NOTE: You must be a currently enrolled Xavier University student or staff member to attend this event.
Full Name: *

First Name Last Name
Address: *
Date of Birth *

Month Day Year
Date
Email Address *
example@example.com
Major or Staff Position: *
What is your Ethnicity? *

American Indian Asian African American Hispanic Native American or Other Pacific Islander Multi-Ethnic Caucasian
What is your Gender? *

Female Male Non-Binary
Have you been diagnosed with Crohn's Disease or Ulcerative Colitis (IBD)? *

Yes No
Do you know what a Chronic Illness Is? *

Yes No
Do you know someone with Inflammatory Bowel Disease (IBD)? *

Yes No
Does anyone in your immediate family suffer from IBD or any other chronic disease? (heart disease, cancer, diabetes, kidney disease, etc.) *

IBD (Crohn's or Ulcerative Colitis) Heart Disease Lupus Cancer Diabetes Kidney Disease Other None Multiple Chronic Diseases
Do you struggle with your mental health? *

Yes No
Do you experience any recurring stomach pain, bloody stool, or any other gastrointestinal symptoms? *

Yes No
Clinical Research Opportunities (please check all that apply) *

I have participated in a clinical research study. I have never participated in a clinical research study. I am interested in learning more about clinical research study opportunities. I have never been asked to participate in any clinical research study opportunities.
Should be Empty:

COCCI Community Conversations