Preemie Crystal Ball
The team at Preemie Crystal Ball has been grateful for the response of the community wanting to #jointhemovement for #preemieoutcomes. That said, before we make a major push toward real change, we wanted to get your feedback on your feelings around research. The survey below is quick and can be anonymous if you wish.
Sign in to Google to save your progress. Learn more
Join the Movement! -
Have you participated in any clinical trials for you or your baby before? *
Do you have an interest in participating in research into prematurity and its legacy into the adult years? *
I am a Parent, Adult Former Preemie, Grandparent of a Preemie, Other *
How do you prefer to provide basic information that can be pooled with other preemies globally? *
How do you want premature infant research to be summarized for you across the lifespan (i.e. I was born at 26 weeks, I am now 30 years old, I have these conditions, x, x, x, etc.)? *
What are barriers to your family participating in research around prematurity from pregnancy on into the adult years? *
Do you have any trust issues with research in this area? *
If you said yes to the above question, can you please provide us with more detail?
Do you have interest in connecting with others who were born at the same gestational age or year or have similar conditions? *
Anything else you want researchers to know? *
Name (if you do not want to provide us with your name, simply put Anonymous) *
Gender? *
Gestational age at birth:
Current age:
Your voice is important to us!
Thank you for taking the time to respond. We greatly appreciate your help. We plan to provide a sample report on social media. Make sure to follow us on:
Facebook: Preemie Crystal Ball (Adult Preemies)
Twitter: Preemie Crystal Ball
Instagram: Preemie Crystal Ball
Clear form
Never submit passwords through Google Forms.
This form was created inside of PreemieWorld, LLC. Report Abuse