Ophthalmology/Eye Institute

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Research Volunteer Form

Advanced Ocular Imaging: Color Blindness

Please select an option below. Please complete all fields.

I am interested in participating in the color blindness study.

I am a parent of someone with color blindness, and I am completing this form for my child.

Your Information

First Name


Last Name


Email Address


Area Code


Phone Number


City, State


Child's name (if applicable)


Please answer Yes or No to the following questions. (You refers to you or your child as appropriate.)

Have you been told by an eye doctor that you have color blindness?

 Yes    No

Are you 18 years of age or older (or a parent of a child at least 5 years of age or older)?

 Yes    No

Have you previously been in a research study at the Eye Institute?

 Yes    No    Not sure

Are you currently or have you ever been a patient at the Eye Institute?

 Yes    No    Not sure

Do you currently hold a valid driver's license?

 Yes    No    N/A (under 18)

Have you had any genetic testing done for your condition?

 Yes    No

Additional Information

Do you have nystagmus?

 Yes    No    Not sure

If yes, please estimate the severity.

 Mild    Moderate    Severe

Please select your type of color blindness below:
 Achromatopsia 
 Blue cone monochromacy
 Red-green color blindness
 Not sure

 


Comments or Questions


 

By submitting this form, I acknowledge that I would like to be contacted about the color blindness study and understand that submission of this form in no way obligates me to participate in this study.

We will contact you as soon as we can.  Thank you for your patience.

If you have questions please contact the Advanced Ocular Imaging Program at (414) 955-2647 (AOIP).

 

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Page Updated 10/22/2013