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

# Text can be put here to explain what the logic/calculation does and why.
if ([field1] = '1' and [field2] > 7,

	// This comment can explain what the next line does.
	[score] * [factor],

	// Return '0' if the condition is False.
	0
)

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Required format:

INFORMATION AND SIGNUP SHEET FOR PARTICIPATION IN RESEARCH

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A A A

David Geffen School of Medicine at UCLA
Department of Neurology
Mary S. Easton Center for Alzheimer's Research and Care at UCLA

Lay Title: UCLA Easton Alzheimer's Disease Center Potential Participant Pool Registry

Technical Title: UCLA Easton Alzheimer's Disease Center Potential Participant Pool Registry

Principal Investigator: Keith Vossel, MD, MSc

INTRODUCTION AND PURPOSE
The Mary S. Easton Center for Alzheimer's Research and Care at UCLA conducts clinical research studies related to Alzheimer's disease (AD). Signing this form indicates that you are willing to have someone from the Center call you and discuss research opportunities. Signing this form does not obligate you to volunteer for any research program, and you can change your mind and refuse discussion with the Center staff if you desire.

ANTICIPATED BENEFITS TO POTENTIAL SUBJECTS AND SOCIETY
The studies conducted at the Center aim to improve diagnosis and find a cure for AD.

PRIVACY AND CONFIDENTIALITY
Information captured in this form or in the follow-up phone call will be confidential. At the discretion of the authorized PI, it may be shared with UCLA collaborative researchers and/or their staff.

PARTICIPATION AND CONSEQUENCES OF WITHDRAWAL
I understand that I am not obligated to sign this form or to participate in research. It has been communicated to me that I may withdraw any recorded information at any time and that doing so will have no impact on the care I receive or my relationship with the staff at UCLA.

SIGNATURE OF RESEARCH SUBJECT
By signing this form, I am granting permission to the research staff of the Mary S. Easton Center for Alzheimer's Research and Care at UCLA to call me and discuss research studies. I understand that if I grant permission during this phone call, the staff will record basic information about me that will be stored in case future studies for which I might be eligible become available. For more information, please contact us at (310) 794-6191.

I acknowledge the above and wish to proceed.

Please click the button to acknowledge before proceeding

* Required

How did you hear about us?

Signed consent to be contacted

Community Event

Clinic Visit

Referral

Web

Other

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Name of Community Event or Speaker

Name of Clinician or Clinic

Name of Referrer

What type of research are you interested in participating in?
Select all that apply

Observational

Interventional

What specific study are you interested in participating in?

First Name

Middle Name

Last Name

Is the contact person different from the potential research participant?

Yes

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Contact Person First Name

Contact Person Middle Name

Contact Person Last Name

Relationship to Potential Research Participant

Phone Number

Best Time to Call

Signature

Add signature

Date

M-D-Y

Protocol ID: IRB#10-001189
UCLA IRB Approved
Approval Date: 4/26/2023
Committee: Medical IRB3

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