Patient Leadership in Research Training Signup

First Name

Last Name

Email Address

Mobile Phone

Zipcode

	Month	Day	Year
Birthdate

Have you been diagnosed with sleep apnea?

Yes, I am a patient with sleep apneaNo, I am a parent or other caregiver of a sleep apnea patientNo, I have not been diagnosed with sleep apnea

What type of sleep apnea have you been diagnosed with? Choose all that apply

How severe is your sleep apnea? Sleep apnea severity is often measured with the Apnea/Hypopnea Index (AHI), or your doctor/sleep study may simply tell you that your sleep apnea is mild, moderate, or severe.

Mild (AHI 1-15)Moderate (AHI 16-30)Severe (AHI 30+)Unsure/Don't Know

Please explain:

Have you ever participated in medical research before? Please select all that apply.

No, I have not participated in medical research beforeYes, as a research subjectYes, as a patient advisor on research designYes, as a student/internYes, as a professional researcher/principal investigatorYes, other

Please explain other

Do you have any experience with or knowledge about Patient-Centered Outcomes Research (PCOR) or Comparative Effectiveness Research (CER)?

YesNoUnsure/Don't know

If yes, please describe:

Why are you interested in participating in sleep apnea research?

Which of the following topics are of most interest to you? Choose all that apply.

Sleep health related topicsSleep apnea related topics

	Morning	Afternoon	Evening
Times

By clicking submit below, I certify that I meet the following requirements to participate in ASAA's Patient Leadership in Research Training:

I have been diagnosed with sleep apnea (obstructive, central, mixed, or UARS), or I am a primary caretaker for someone diagnosed with sleep apnea.
I am at least 18 years old, or at least 13 years old with a parent or legal guardian's permission to participate.
I can understand, speak, read, and write English.
I have access to a computer, tablet, or smartphone; access to high-speed internet; and am willing and able to use Zoom for virtual meetings.
I am willing to commit to up to 45 minutes of material review prior to each training sessions and will complete related surveys and assessments.
I am willing to share my opinions, experiences, and feedback with ASAA staff and other PLRT participants.
I am willing to receive occasional communications from ASAA about potential opportunities to participate in PCOR/CER sleep apnea research design.