COCCI Community Conversations
Virginia State - November 7, 2022 PLEASE NOTE: You must be a currently enrolled VSU student or staff member to attend this event.
Full Name:
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First Name
Last Name
Address:
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Date of Birth
*
-
Month
-
Day
Year
Date
Email Address
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example@example.com
Major or Staff Position:
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What is your Ethnicity?
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American Indian
Asian
African American
Hispanic
Native American or Other Pacific Islander
Multi-Ethnic
Caucasian
What is your Gender?
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Female
Male
Non-Binary
Have you been diagnosed with Crohn's Disease or Ulcerative Colitis (IBD)?
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Yes
No
Do you know what a Chronic Illness Is?
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Yes
No
Do you know someone with Inflammatory Bowel Disease (IBD)?
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Yes
No
Does anyone in your immediate family suffer from IBD or any other chronic disease? (heart disease, cancer, diabetes, kidney disease, etc.)
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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?
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Yes
No
Do you experience any recurring stomach pain, bloody stool, or any other gastrointestinal symptoms?
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Yes
No
Clinical Research Opportunities (please check all that apply)
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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.
Submit
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