Survey | Qualtrics Survey Software

Thank you for your interest in the Longitudinal Health and Intellectual Disability Study!

To register, please enter the information below. After you have completed this form, click on the 'Next Page' button.

If you are having trouble reading this page, please click the "+" button on your keyboard while holding down the "Ctrl" key. This will increase the font size in your browser window.

Full name of contact person/caregiver:

First name
Last name

Contact person street address:

Street Address 1:
Street Address 2:

Contact person city, state, and zipcode:

City:
State:
Zipcode:

Contact person telephone:

Example: 123-123-1234

Alternate contact number:

Example: 123-123-1234

Contact person email address:

Example: smith@smith.com

Full name of person with an intellectual disability. (If you are this person and will be filling out the survey on your own, simply write "Self" in the boxes below.)

First name
Last name

Please note the person for whom you are a primary caregiver must be 18 years or older and currently residing in the United States to participate.

Date of birth of person with an intellectual disability (for example, 10/4/79):

Date of birth of person with an intellectual disability (for example, 10/4/79):

			Month	Day	Year			Don't know
Date of Birth

Would you like to take the survey in paper form or online?

I would like to take the survey in paper form.
I would like to take the survey online.