Form

Stevens Johnson Syndrome / Toxic Epidermal Necrolysis

Please complete the Survey Below Thank You!
You are invited to complete this pre-screening survey to see if you might be a good fit for the Genetic Risk and Long-Term Outcomes Associated with Drug-induced Stevens-Johnson syndrome and Toxic Epidermal Necrolysis research study.

Thank you for your interest in the SJS Research Consortium Study.
Are you interested in participating in or learning more about this research study?

YesNo
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Diagnosed with SJS / TEN?

YesNo
How long hospital stay?

1 week4 weeksLonger
Caused by a Medication?

LamitcalBactrimOther
To confirm SJS / TEN diagnosis for the study, would you be willing to submit medical records to our research team?

YesNo
Permission for investigator to retain information and contact individual with future drug hypersensitivity study opportunities

YesNo
Do you give your permission SJS Research Consortium to keep your answers on file and contact you regarding your willingness to participate in future studies about drug hypersensitivity?

YesNo, I would like my answers and contact information destroyed when the SJS Research Consortium Survey is over.
Comments
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Stevens Johnson Syndrome / Toxic Epidermal Necrolysis