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