This section will enable when a specific study requires an alternate contact, such as a caregiver, who is not the recipient’s parent / guardian. This section is currently disabled as it is not required for the following studies: BMT CTN 1702, BMT CTN 1703, or BMT CTN 1704.
Question 39: Does the study require additional participant’s contact details?
This question is currently disabled. This question will indicate if the study in which the recipient is enrolled requires contact information for additional individuals besides recipient and parent / guardian.
Question 40: Relationship to recipient
Indicate the alternate contact’s relationship to the recipient. If the relationship is not listed as an option value, select ‘other’ and proceed to question 41.
Question 41: Specify other relationship:
Indicate the alternate contact’s relationship to the recipient in the open text field provided.
Question 42 – 43: First Name, Last Name
Report the alternate contact’s complete legal first name in question 42 and complete legal last name in question 43.
Question 44: Indicate language preference:
Select the alternate contact’s primary language. If the alternate contact’s language is not listed as an option value select ‘other’ and proceed to question 45.
Question 45: Specify other language preference:
Indicate the alternate contact’s language preference in the open text field provided.
Question 46: Does the alternate contact have the same contact information as the recipient? (completed above)
If the alternate contact resides at the same street address as the recipient then select ‘yes’ to question 46.
Question 47: Does this contact have a U.S. mailing address?
Indicate if the alternate contact has a street address located in the U.S. (only inclusive of the 50 states and Washington D.C.). If the alternate contact resides in a U.S. territory including: Puerto Rico, Northern Mariana Island, United States Virgin Islands, American Samoa, or the United States minor outlying islands, then answer ‘no’ and complete the form using the international address question format in question 49.
Question 48: Street, City, State, Zip code
Indicate the alternate contact’s current U.S. home address.
Question 49: Country, International address
Indicate the alternate contact’s current international home address.
Question 50: Specify time zone (of mailing address)
Indicate the time zone of the alternate contact’s mailing address as based off of Universal Coordinated Time (UTC). If the alternate contact has a U.S. mailing address within the Samoa or Chamorro time zone or has an international mailing address, then select ‘other’ and report time zone in question 51.
Question 51: Specify other time zone:
Only answer this question if the time zone for the alternate contact’s mailing address was not listed above. Indicate time zone in the open text field.
Question 52 – 55: Phone number(s) – Home / Work / Cell / Other:
For questions 52 – 55, provide phone numbers at which the alternate contact can be contacted for each type of phone number available. A phone number does not need to be provided for each phone number type however; at least one phone number is required.
Indicate area code when reporting U.S. phone numbers. Indicate country code for all international phone numbers.
Question 56: Specify other phone number type:
If the alternate contact’s preferred phone number type is not a home / work / or cell phone number, indicate the other phone number type here.
Questions 57 – 58: E-mail address(es) – primary / secondary
Indicate the alternate contact’s primary and secondary e-mail address (if applicable). When using the open text field be sure to provide a complete e-mail address including: user e-mail prefix, “@” symbol, and e-mail domain (ex: JohnDoe@comcast.net, JaneDoe@gmail.com)
Section Updates:
| Question Number | Date of Change | Add/Remove/Modify | Description | Reasoning (If applicable) |
|---|---|---|---|---|
| . | . | . | . | . |