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

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The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

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This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

khsjWGRriReZJesIz65as3FHyc

Contact Information Form

Thank you for your past participation in The Muscatine Study. We hope you choose to participate in this new study.

Please complete and press the "Submit" button at the end of the survey to send your information.

Thank you!

Today's Date

M-D-Y

We invite you to participate in this exciting and important new phase of The Muscatine Study

I would like to participate

I would like to participate, but not right now, please contact me again in three months

I do not want to participate

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I am completing this form as

A Muscatine Study participant

The proxy for an incapacitated Muscatine Study participant

The proxy for a deceased Muscatine Study Participant

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Thank you for your interest in this study. We will keep your information on file and contact you in three months. Press SUBMIT at the end of the form to send us your information.

We're sorry you decided not to participate. Please provide your name and date of birth below so we can remove you from future mailings for this study. Thank you for your previous support of The Muscatine Study.

Please complete the form and we will update the participant's information in our records. We appreciate their previous support of The Muscatine Study. Thank you for your help.

We will need to contact you by phone to obtain additional information about the former Muscatine Study participant, which should take no more than 20 minutes of your time. Please provide your contact information and indicate the best times to reach you by phone. Press SUBMIT at the end of the form after providing information about the participant to end the survey and send the information.

What is your relationship to the participant?

Spouse

Sibling

Child

Friend

Parent

Other

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What is your first name?

* must provide value

What is your last name?

* must provide value

What is your home phone number?

What is your cell phone number?

What is your email address?

* must provide value

The study staff will use this information to obtain additional details about the medical cause of death from the U.S. National Death Index (NDI; a registry of all deaths in the U.S. since 1979) and request the participant's death certificate. It may also be necessary for study staff to request access to the participant's medical records from just before death. This is important for the successful completion of the research study, to make sure that all cardiovascular-related deaths are accurately accounted for, and non-cardiovascular deaths are verified as well.

All of this information will be held confidentially, with precautions against unintended use and disclosure of this information. The process for obtaining this information has been approved by the ethics review board at The University of Iowa.

If it is necessary for the study to obtain the deceased participant's medical records, we will need to ask permission from the participant's executor, spouse or next of kin, depending on the laws of the state where the participant died. In that case, we may contact you again to discuss this process. If you have any questions or concerns about the use of this information for this research study, please contact Jeni Michelson at 319-335-6983, jeni-michelson@uiowa.edu.

What restrictions does the participant have?

Please complete the remainder of the form as if you were The Muscatine Study participant. Thank you for your help with this study.

First Name

* must provide value

Middle Name

Last Name

* must provide value

Maiden Name (if applicable)

Date of Birth

* must provide value

M-D-Y

Please provide your current contact information below:

Street address

City

State

If you no longer live in Iowa, what year did you move out of Iowa?

Zip Code

Home Phone Number

Work Phone Number

Cell Phone Number

Is it okay to text you with study information?

Yes

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What is your email address?

* must provide value

What is your Facebook account?

Is it okay to contact you through Facebook messenger (private messages)?

Yes

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______, we will be contacting you by phone within the next two weeks to discuss the study and your participation. Please let us know good times of day and the best number to reach you during that time:

______ and ______, we will be contacting you by phone within the next two weeks to discuss the study and your participation. We would like to speak to you when you are together. Please let us know good times of day and the best number to reach you during that time:

Home

Work

Cell

Not Available

Weekday Morning (9-11 am)

Weekday Mid-day (11 am-2 pm)

Weekday Afternoon (2-5 pm)

Weekday Early Evening (5-8 pm)

Saturday (10 am-3 pm)

Sunday (10 am-3 pm)

During the phone call, we will discuss the Heart Health Survey that will take about 20 minutes to complete.

I would prefer to complete the Heart Health Survey:

On-Line

By Phone

By Mail

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We will send a link to the survey specific to you via email. We still want to talk to you on the phone but will only take about 5 minutes.

What is your relationship to the participant?

Spouse

Sibling

Child

Friend

Parent

Other

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What is The Muscatine Study participant's first name?

* must provide value

What is The Muscatine Study participant's middle name?

What is The Muscatine Study participant's last name?

* must provide value

What is The Muscatine Study participant's maiden name (if applicable)?

What is The Muscatine Study participant's date of birth?

What is the Muscatine Study participant's date of death?

If you do not know the date, please provide their age at death:

Cause of death

Participant's Social Security #

U.S. state or non-U.S. country where participant died

If the participant was no longer living in Iowa, when was the last time their official residence was in Iowa?

Location of death

Home

Hospital

Hospice facility

Other location

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Please provide contact information for 2 people who do not live with you, but will know how to contact you if you move. When you have provided as much information as you can, press SUBMIT to end the survey and send the form. Thank you.

Please provide contact information for 2 people who do not live with ______, but will know how to contact ______ if they move. When you have provided as much information as you can, press SUBMIT to end the survey and send the form. Thank you.

Contact Person #1 First Name

Contact Person #1 Last Name

How is ______ related to you?

Child

Sibling

Parent

Friend

Co-worker

Other

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______'s street address

______'s city

______'s state

______'s phone number

______'s email address

Contact Person #2 First Name

Contact Person #2 Last Name

How is ______ related to you?

Child

Sibling

Parent

Friend

Co-worker

Other

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______'s street address

______'s city

______'s state

______'s phone number

______'s email address

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.