COCCI Community Conversations
Texas Southern University - October 5, 2022 PLEASE NOTE: You must be a currently enrolled Texas Southern University student or staff member to attend this event.
Full Name:
*
First Name
Last Name
Address:
*
Email:
*
example@example.com
Date of Birth:
*
MM/DD/YYYY
Major or Staff Position:
*
What is your Ethnicity?
*
American Indian
Asian
African American
Hispanic
Native American or Other Pacific Islander
Multi-Ethnic
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 not participated in a clinical research study.
I am interested in learning about clinical research studies.
I have never been asked to participate in any clinical research study opportunities.
Submit
Should be Empty: