The code block below illustrates how one might use # and // as comments in your logic and calculations.

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Required format:

ROSE STUDY: Interest Form

Thank you for your interest in the Research OutSmarts Endometriosis (ROSE) study.

Please complete the form below.

This form will ask questions regarding study eligibility. Once complete, you will proceed to enroll in the study.

Participation in the ROSE Study enrollment process includes:

Completing a Consent Form
Completing Questionnaires
Providing Sample(s)

Information entered into this system is secure and confidential.

Email: ROSE@northwell.edu
Phone: 516-562-3636 (ENDO)

Interest Form Entered Manually?

* must provide value

Yes No

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Today's Date:

* must provide value

M-D-Y

Are you 18 years of age or older?

* must provide value

Yes No

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Are you a resident of the United States, Canada or Puerto Rico?

* must provide value

Yes No

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Are you interested in learning more about the ROSE study on behalf of Yourself or Someone Else?

* must provide value

Myself

Someone Else

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Is this person an adult?

* must provide value

Yes No

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Are you the parent or legal guardian of this person?

* must provide value

Yes No

reset

Are you currently pregnant?

* must provide value

Yes No

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Are you currently breast-feeding?

* must provide value

Yes No

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Have you been diagnosed with endometriosis or have symptoms of endometriosis?

Symptoms may include painful periods, pelvic pain, chronic abdominal bloating, heavy periods, pain with sex, pain with urination or pain with bowel movement.

* must provide value

Yes No

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You chose 'Yes'. Please choose one of the following that best describes you:

* must provide value

Surgically diagnosed with endometriosis (with a pathology report)

Symptoms of endometriosis without surgical confirmation

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You chose 'No". Please confirm the following:

* must provide value

NO symptoms of endometriosis (control)

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Do you still get your period (menstruation)?

* must provide value

Yes No

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Are you willing to provide the study with a sample of your menstrual effluent/blood (ME)?

* must provide value

Yes No

reset

At this time you are ineligible to participate.
Please contact us when the time is right.

Email: rose@northwell.edu
Send Email

Regretfully, at this time the ROSE study is unable to accommodate enrollment outside of the USA/Canada and Puerto Rico areas.

If you have any questions, please contact us by email at: rose@northwell.edu
Send Email

At this time you are ineligible to participate.

If you have questions, please contact a ROSE coordinator by email: rose@northwell.edu
Send Email

Please ask this individual to complete the
Interest Form on their own behalf.

If you have any questions, please contact us by email at: rose@northwell.edu
Send Email

Please enter your information below and a ROSE coordinator will contact you.

What is your First Name?

* must provide value

What is your Last Name?

* must provide value

What is your FIRST and LAST name?

* must provide value

What is your child's FIRST name?

* must provide value

What is your child's LAST name?

* must provide value

STAFF: BELOW IS THE ADULT SUBJECT OR PARENT EMAIL ADDRESS

What Email Address should we use to contact you?

* must provide value

Please verify Email Address:

* must provide value

STAFF: BELOW IS THE MINOR EMAIL ADDRESS

What Email Address should we use to reach you?

* must provide value

Please re-enter Email Address:

* must provide value

(Email Addresses entered do not match. Please correct, thank you.)

Please enter your Parent or Legal Guardian's Full Name

* must provide value

What is your Parent or Legal Guardian's Phone Number?

* must provide value

Which Phone Number is best to contact you?

* must provide value

Cell

Home

Work

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Please Enter Cell Number

* must provide value

Please Enter Home Number

* must provide value

Please Enter Work Number

* must provide value

Are you willing to receive text messages regarding the next step for the ROSE study?

* must provide value

Yes No

reset

Please CONFIRM Cell Number

* must provide value

You are eligible to participate in the ROSE Study!

As an unaffected participant (control)
in the study, you will become a valuable
asset in understanding women's health.

PLEASE SUBMIT THIS FORM.
We will contact you soon for the next step.
The ROSE Study Team

You are eligible to participate in the
ROSE Study!

Click SUBMIT
to access the
Informed Consent and
Study Questionnaires.

Thank you for completing the Interest Form!

Please Submit the form and a research coordinator will contact you.

Thank you for completing the Interest Form!

Please Submit the form and let your parent/legal guardian know to expect a call from the ROSE team.

Please contact the ROSE team at 516-562-3636.

Speak with Parent and obtain permission.
Check YES for Parent/Legal Guardian Contact and add Date of Parent Call.
Confirm Minor’s Full Name, Affected/Control and DOB and document under Parent/Legal Guardian Contact.
Review with Parent where to send minor assent (parent or minor email address).
Speak with Minor and check YES in Minor Contact.
If Minor is amenable, check YES to Trigger Parental Consent Invitation.
Confirm where to Send Assent. If sending to Minor email, add email address and confirm cell number.
Add Date of Minor Call.
Send Minor Assent.
If Parent Consent for Minor is completed, complete Documentation of Informed Consent. DO NOT generate StudySubjectID.
If Minor Assent is completed, complete Documentation of Informed Consent Minor.
Go back to Documentation of Informed Consent and click YES to Participant Successfully Consented/Declined? to trigger StudySubjectID.

Spoke with Parent/Permission Given

Yes

Date of Parent Call

* must provide value

M-D-Y

Confirm Minor Full Name

Yes

Confirm Minor Affected or Control

* must provide value

Minor Affected

Minor Control

reset

Enter Minor DOB

M-D-Y

Minor Current Age

View equation

Where to Send Assent

* must provide value

Send to Parent/Legal Guardian Email

Send to Minor Email

reset

Enter Minor Email Address (SCROLL UP).

Enter Parent/Guardian Email Address (SCROLL UP).

Spoke with Minor

Yes

Minor Email Address Confirmed

Yes

Date of Minor Call

M-D-Y

Trigger Parental Consent Invitation

Yes No

reset

Parental Consent Sent Date

M-D-Y

REDCap will send Parental Consent automatically when form is saved as COMPLETE.

Comments

Expand

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.

ROSE STUDY: Interest Form

At this time you are ineligible to participate. Please contact us when the time is right. Email: rose@northwell.edu Send Email

Regretfully, at this time the ROSE study is unable to accommodate enrollment outside of the USA/Canada and Puerto Rico areas. If you have any questions, please contact us by email at: rose@northwell.edu Send Email

At this time you are ineligible to participate. If you have questions, please contact a ROSE coordinator by email: rose@northwell.edu Send Email

Please ask this individual to complete the Interest Form on their own behalf. If you have any questions, please contact us by email at: rose@northwell.edu Send Email

You are eligible to participate in the ROSE Study! As an unaffected participant (control) in the study, you will become a valuable asset in understanding women's health. PLEASE SUBMIT THIS FORM. We will contact you soon for the next step. The ROSE Study Team

You are eligible to participate in the ROSE Study! Click SUBMIT to access the Informed Consent and Study Questionnaires.

Thank you for completing the Interest Form! Please Submit the form and a research coordinator will contact you.

Thank you for completing the Interest Form! Please Submit the form and let your parent/legal guardian know to expect a call from the ROSE team.

You have selected an option that triggers this survey to end right now.

At this time you are ineligible to participate.
Please contact us when the time is right.

Email: rose@northwell.edu
Send Email

Regretfully, at this time the ROSE study is unable to accommodate enrollment outside of the USA/Canada and Puerto Rico areas.

If you have any questions, please contact us by email at: rose@northwell.edu
Send Email

At this time you are ineligible to participate.

If you have questions, please contact a ROSE coordinator by email: rose@northwell.edu
Send Email

Please ask this individual to complete the
Interest Form on their own behalf.

If you have any questions, please contact us by email at: rose@northwell.edu
Send Email

You are eligible to participate in the ROSE Study!

As an unaffected participant (control)
in the study, you will become a valuable
asset in understanding women's health.

PLEASE SUBMIT THIS FORM.
We will contact you soon for the next step.
The ROSE Study Team

You are eligible to participate in the
ROSE Study!

Click SUBMIT
to access the
Informed Consent and
Study Questionnaires.

Thank you for completing the Interest Form!

Please Submit the form and a research coordinator will contact you.

Thank you for completing the Interest Form!

Please Submit the form and let your parent/legal guardian know to expect a call from the ROSE team.