Spina Bifida Association

of Washington State

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formerly, the Evergreen Spina Bifida Association

Hello!

The Rehabilitation Research and Training Center for Health and Wellness for People with Disabilities (RRTC) at Oregon Health & Science University (OHSU) is conducting a study about how to measure the health and quality of life of people with disabilities. We are wondering if you would be willing to forward the study description and sign-up sheet below to your eligible staff, board members, and colleagues.

Study participants will receive $25 in gift cards. Dr. Willi Horner-Johnson at Oregon Health & Science University (OHSU) is leading the study. OHSU also is working with researchers from the University of Florida, University of Illinois-Chicago, Baylor University, Southern Methodist University, and Oregon State University.

Who can participate?

To be able to take part in the study, you must:
* Be a man at least 18 years old.
* Have a physical, mental health, or emotional condition that has lasted for six months or longer.
* Live in Oregon, Washington, or Idaho.

What do I need to do?

You will fill out 2 surveys about your health and well-being, one month apart. The RRTC will send you the first survey with a stamped, addressed envelope for you to return the survey within one week. About three weeks later, the RRTC will send you the second survey, also with a stamped, addressed envelope for you to return that survey within one week.

What will I get by taking part in the study?

If you complete and send back the first survey WITHIN A WEEK of receiving it, you will receive a $10 gift card. If you complete and send back the second survey WITHIN A WEEK of receiving it, you will receive another gift card for $15.

What about confidentiality?

All the information the researchers gather will be kept confidential.

How do I sign up to take part in the survey?

You may fill out the survey information below, or contact the RRTC at:
Phone: 503-494-3534 or 1-877-550-7070 (voice) ~ 7-1-1 (relay service)
Please call Mondays – Fridays between 8:30 AM and 4:00 PM Pacific Time
Email:
rrtc@ohsu.edu

SURVEY SIGN-UP INFORMATION eIRB # 3368

Please complete this form if you would like to help OHSU with a health measurement research study. You are eligible to take part in this survey if you are:

1) a man at least 18 years old.

2) limited in any way in any activities because of physical, mental health, or emotional conditions that have lasted for 6 months or more.

3) living in Oregon, Washington, or Idaho.

We will mail you 2 surveys (about three weeks apart) and will give you a gift card for completing and returning each survey WITHIN 1 WEEK of getting it. We will send you a $10 gift card for the first survey and a $15 gift card for the second survey. You do not need to travel or take part in any meetings or see any doctors.

All personal information will be kept strictly confidential. Your personal information will not be shared.

Note: The sign up form has not been set up as a typical internet or online form. Instead, it has been set up using text. You will need to use the “reply” feature of your email program to type in any information, or copy and paste the questions into a word processing program and then attach the document. After you read the question (and any options) you will find the word “Answer:” with a line next to it. Please type your answer or the answer number on that line. When you are finished, you may return your information to us using any of the methods described at the end of the sign up form.
Thank you for your interest in this important research study!


What is your first name?
Answer: ___________

What is your last name?
Answer: ___________

What is your mailing address?
Answer: ___________

City:
Answer: ___________

State:
Answer: ___________

Zip Code:
Answer: ___________

What is your telephone number?
Answer: ___________

Do you have an e-mail address we can use for communicating with you about the study?
Answer: ___________

How old are you?
Answer: ___________

What is your gender? 1. Male 2. Female
Answer: ___________

What is the highest grade in school you completed? (choose one)
1. Did not receive high school diploma or GED
2. High school graduate (diploma or GED)
3. Some college but no degree
4. Technical school or associate’s degree
5. 4-year college graduate
6. Graduate degree
Answer: ___________

Surveys are printed in 14 point Arial font and sent by U.S. mail. Will you need the surveys in an alternate format?
1. Yes
2. No
Answer: ___________

If yes, please tell us what format will work for you:
1. Large print
2. Electronic format (text only, suitable for people using screen readers)
3. Other (specify)
Answer: ___________

My disability category is:
1. Vision
2. Hearing
3. Physical
4. Mental health/emotional
Answer: ___________

Would you like us to keep your information on file so that we can contact you for future studies?
1. Yes
2. No
Answer: ___________

You may return this information to us any of the following ways:

1) Fax this completed information sheet to 503-494-0931.
2) Phone in the information to 503-494-3534 or 1-877-550-7070 (voice) ~ 7-1-1 (relay service) Please call Mondays – Fridays between 8:30 AM and 4:00 PM Pacific Standard Time.
3) Email the information to:
rrtc@ohsu.edu
4) Mail this information sheet to:
Oregon Health & Science University
CDRC, RRTC attn: Spielman
P.O. Box 574
Portland, OR 97207-0574


Thank you for your time,

Amy Sharer
RRTC Student Assistant
Rehabilitation Research and Training Center on Health & Wellness
CDRC, Oregon Health and Science University
707 SW Gaines Street
Portland, OR 97239
sharera@ohsu.edu
503-494-3534
Toll-free: 1-877-550-7070
TTY: 7-1-1